Name:__________________________________________________ Age _______
Address __________________________________________________________________
City, State, Zip Code ________________________________________________________
email Address _____________________________________________________________
Home Phone _____________________ Cell __________________ Work _____________
Best time to call which number_______________________________________________
Childrens Ages ____________________________________________________________
Spouse's Occupation _______________________________________________________
If prestent relationship were to change, who would keep the bird? __________________
Do all members of your household know you plan to adopt a bird? _________________
Who will be the birds primary caretaker? _______________________________________
How many hours a day would the bird be alone? ________________________________
Type of dwelling: Single house ___ Condo ___ Apartment ___ Other ___
Do you rent of own? Rent ___ Own ___ If you rent, do you have the landlords
permission to have a bird? _______
Does anyone in your house smoke? ____
Do you have other pets? ___ If yes, How many and what are they? ____________________
____________________________________________________________________________
What type of bird are you looking to adopt? _______________________________________
Will you accept a bird with behavioral problems? ____ or a handicapped bird? _____
If you travel, who would care for the bird whi;e you were away? _______________________
_____________________________________________________________________________
Do you have an Avian vet? ___ Do we have permission to contact your vet for a refrence? ___
If yes, enter the name, address and phone number ____________________________________
_____________________________________________________________________________
How did you hear about this rescue? ______________________________________________
Please list three personal refrences and contact information: __________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PLEASE CONTINUE ONTO PAGE 2
Reviewed By: : _______________________ Home Visit Date: ____________
