Please take a few minutes to fill out this survey it will help us place a suitable dog for your home.

Personal Information
Name *
Name
Address *
Address
Phone *
Phone
How many hours do you spend at work away from home? *
Are you currently a full time or part time student? *
How did you find out about the Babinski Foundation?
General Housing Information
Do you rent or own your home? *
If you are renting, we require a signed letter on letterhead from the landlord.
Type of Home: *
Landlord's Phone Number
Landlord's Phone Number
Do you have a fenced in yard? *
Fence type:
Will the dog be kept inside or outside? *
Where will the pet stay when home alone? *
Do you currently have a veterinarian? *
Veterinarian's Phone Number
Veterinarian's Phone Number
Would you tolerate potty accidents in the home? *
What traits would you not tolerate with your new dog? *