Household Information. Today’s Date: / / If you are not the parent of child(ren) for whom you are applying, are you the Primary Adult Caretaker*? Are there other Adult Caretaker(s) in the household*? *Primary Adult Caretaker’s Last Name: *Primary Adult Caretaker’s First Name: Middle Initial: Do any of the following apply to your current living situation? Please complete if applicable. housing such as car, park, etc. Living situation (please explain) Date living situation began: / / Anticipated end date: / / Residence Address*: City*: State*: Zip*: City*: State*: Zip*: County*: Primary language spoken in the home*: Contact Information: *Complete at least one Primary Phone*: ( ) Type: Home Cell Voice Msg. Work Secondary Phone*: ( ) Type: Home Cell Voice Msg. Work Email Address: Do you or anyone else in your household receive benefits from or participate in any of the following programs? If no, would you like to receive more information? Colorado Works/TANF cash assistance Head Start/Early Head Start Low-Income Energy Assistance (LEAP) Food Assistance (SNAP) Women, Infants and Children (WIC) Program Child and Adult Care Food Program Medicaid/CHP+ Assistance Housing voucher or cash assistance Refugee Medical Assistance Individuals with Disabilities Education (IDEA) Services Part B (3-5yrs) Individuals with Disabilities Education (IDEA) Services Part C (0-3yrs) Old Age Pension Other (please explain):_ Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 1 615-82-14-0028 (rev12/2015) All Items Marked with (*) on this application MUST be completed
Household Information a. The Nanny may have friends or relatives visit her in the Family home. Yes No
Household Information. Do you live in a: Xxxxx Xxxxxxxxx Xxxxxx home Do you Own Rent (landlord’s name & number): How long have you lived at your current address? If less than 6 months then previous address Household activity level: Quiet Average Active Does anyone in household have allergies / asthmatic around dog(s) Yes No Do you have a fenced yard: Yes No / Partially fenced? Yes No Current Pet Information List all current and previous pets (last 5 yrs): Type of Animal Age Sex (M/F) Neutered (Y/N) Still in household (Y/N) Veterinarian name: Phone number Pets Vaccinations Current: Yes No General Information Have you ever utilized any services of Starting Over Animal Rescue before? Yes, If yes, why? No Have you ever surrendered, returned, lost, or given up any previous pet? Yes, If yes, why? No It can take a dog 2 weeks or more to settle in a new environment. Are you willing to give it time to adjust? Yes No Who will be the primary care giver? Relationship to applicant? _ Why do you want this dog? Are you prepared/able to make a lifetime commitment to care for/keep this dog as a companion pet? Yes No Are you able and willing to pay for pet expenses including vet care, supplies, pet-sitting, training, etc.? Yes No Where will the dog be kept when you are home? Not home? How long will the dog be alone daily? Where will the dog sleep at night? Our dogs may not be fully house broken. Are you willing to provide consistent house training? Yes No Are you familiar with house training procedures? Yes No. How long do you think house training will take? . How often and what types of exercise will your dog receive? How do you plan to train the dog? Are you familiar with Positive Training? Yes No Are you familiar with Treat Training? Yes No How will you address behavioral issues? Are you aware that bored dogs will chew / be destructive if not properly socialized, trained, or played with? Yes No List the types of behavioral issues that you would consider NOT ACCEPTABLE: In what circumstances would you give up your dog? (ex. unable to house train, chewing, moving, etc..) Applicants must be 18 yrs of age (or older), have a valid photo ID with current address, and written permission from landlord to own a pet. Starting Over Animal Rescue (SOAR) reserves the right to contact individuals and verify all information, including conducting a home visit and vet check. To the best of my knowledge, the information provided is complete ...
Household Information. Please list ALL of the people that will occupy the rental unit, including the head of household. Attach an Additional sheet if necessary First & Last Name Birth date Social Security # Relationship Tribe Enroll No. Head of House
Household Information. Please complete this section for the household in which your animal will reside. Living accommodations: Rent Own Other If rent, provide the name and phone no. of your landlord ________________________________________. We must receive written or verbal approval from your landlord before an adoption may be approved. Do you have a fenced- in yard? ______. If no, how will you keep your animal contained? ___________________________ Where will your new pet live? In home In yard Other_________________________ How many adults live in this household? ______ How many children? ______ Ages of children in this household? _________________________ Are all members in your household in agreement about adopting an animal (this includes roommates)? Yes No
Household Information. Household members include: # of Adults # of Children Are there any pets in the household? ◻ Yes ◻ No If yes, what kind and how many? Will Employee be expected to care for the pets? ◻ Yes ◻ No
Household Information a. The nanny may have visitors in the family home. Yes No If yes, 24 hour advance notice must be provided and number of guests should be limited to no more than at a time.
Household Information. Indicate the current status of all adults and children that will live in the housing unit to be assisted. Add new members in the space provided below, including the full Social Security Number for each. Enter one of the following codes in box 6 to identify the relationship of each new adult and child listed. H = Head of Household S = Spouse (Married) K = Co-Head (Not Married) F = Xxxxxx Child/Adult Y = Youth Under 18 E = Full Time Student Over 18 L = Live-in Aide A = Other Adult
Household Information. 3a. List yourself, then all other household members. If required, attach separate sheet for more names. Relationship Birth Date Born in Last Name First Name & Initial (to Applicant) (dd/mm/yyyy) Age Sex Canada?
Household Information. Main telephone number of the household: X Main email of the Member: X Names of each additional person living at the above address and approved for occupancy by the Cooperative: Occupant Name: X □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) Occupant Name: □ (Check if over the age of 18) Additional occupants names: SAMPLE
