Name:      
Address:   
City:               State:          Zip Code
Phone:             Work Phone:     
E-mail:     
Emergency contact and phone number:     

How many of each in your household?
Adults:    Children:    Childrens' Ages?

Who will be the primary caretaker of the rabbit(s)?

Is there anyone in your family who is allergic to rabbits or hay? Yes No

Do you currently own or rent?
If renting, what pets does your landlord allow?

If you move, what will you do with the rabbit(s)?

Please list other pets you've had, past and present (list current animals first).

Type of Animal	Age	Spayed/Neutered?	If you no longer have the animal, please tell what happened.
		Yes No
		Yes No
		Yes No
		Yes No
		Yes No
		Yes No
		Yes No

What pet behaviors are unacceptable in your home?

You will be responsible for medical care expenses.
What do you expect to spend each month?

Veterinarian Name and Vet Clinic:

Are you able to transport your rabbit to and from weekend outreaches? Yes No

What research or reading have you done about companion rabbits?

What first hand experience have you had with companion rabbits?

Why do you want to be a rabbit guardian?

How do you plan to house the rabbit(s)?

Would you like assistance in planning your rabbit's housing? Yes No

Will you rabbit be allowed outdoors? Yes No
If yes, under what circumstances?

Name some reasons that would cause you to be unable to continue being a guardian to your rabbit:

How long will you be able to continue as a guardian?

Do you have:? Auto insurance Home owner or liability insurance
You will be asked to furnish a copy of your driver's license or photo identification.

Have you read and are you in agreement with our mission statement and philosophy statement?
Yes No
If no, please explain: