Adopters Name *

First Name

Last Name

Age *

18-25

26-45

46-65

66+

Partners Name

First Name

Last Name

Partners Age

18-25

26-45

46-65

66+

Do you have any children living (full or part time) in your home? *

Yes

No

Phone No.

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Who will be the bird's primary caregiver? *

Self

Partner

Other

What type is your residence? *

House

Condominum

Apartment

Other

Do you rent or own your home? *

Rent

Own

If rent, does your landlord allow pets?

Yes

No

Does anyone in your household have a health condition(s) that could restrict his/her ability to handle/care for a bird?

Yes

No

Does anyone in your home have allergies? *

Yes

No

Do you currently have other birds living in your home?

Yes

No

Does anyone in your home smoke?

Yes

No

Have you previously owned birds you no longer own?

Yes

No

Do you currently have any other pets living in your home?

Yes

No

Do you currently have an avian veterinarian?

Yes

No

Avian Vet Name

First Name

Last Name

Clinic Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Clinic Phone

(###)

###

####

What type of bird are you interested in (check all that apply)? *

small bird (cockatiel, lovebird, finch)

medium bird (conure, lory)

large bird (african grey, amazon)

xl bird (cockatoo, macaw)

not sure yet - help me decide

I understand this bird must remain in my home. If my circumstances change, I understand I must contact A Helping Wing. I will forward any changes to my address(es) and/or phone number(s) to A Helping Wing. I also agree to a home visit prior to approval, and I understand that A Helping Wing representative may make periodic visits to my home. I also understand that A Helping Wing may contact my references prior to approval of this application. *

I agree to these conditions