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Dog Adoption Application

Adoption

Adoption form information fields

1Applicant

2Family

3Home

4Care

5Preferences

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Default: Adopter Status
First Name*
Last Name*
Age Range*
eMail Address*
eMail Address Confirm eMail Address
Street Address*
Suite | Apt or Unit Number
City*
State/Province*
ZIP*
Country
Home Phone Number
Work Phone Number
Cell Phone Number*
- Preferred Method of Contact*
Employment & Schooling
- Are You Employed?*
  - Yes
  - No
  - Retired
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  Full or Part Time?*
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  Name of Employer
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  How Long Employed There?
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  Are You in School?*
  - Yes
  - No
- This field is hidden when viewing the form
  Full or Part Time?*

Below are three areas for information on other members of your family. Please include all other adults, children and pets living in your home by clicking on the designated button.
Adults
Are There Other Adults In The Home?
- Yes
- No
How Many?*
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How Many?*
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Adult 1
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First Name*
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Last Name*
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Age Range*
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Gender*
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Relationship To Applicant*
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Please Describe*
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Phone Number*
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eMail Address*
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Are They Employed?*
- Yes
- No
- Retired
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Full or Part Time?*
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Name of Employer*
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How Long Employed There?*
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Are They in School?*
- Yes
- No
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Full or Part Time?*
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Adult 2
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First Name*
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Last Name*
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Age Range*
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Gender*
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Relationship To Applicant*
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Please Describe*
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Phone Number*
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eMail Address*
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Are They Employed?*
- Yes
- No
- Retired
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Full or Part Time?*
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Name of Employer*
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How Long Employed There?*
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Are They in School?*
- Yes
- No
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Full or Part Time?*
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Adult 3
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First Name*
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Last Name*
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Age Range*
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Gender*
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Relationship To Applicant*
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Please Describe*
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Phone Number*
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eMail Address*
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Are They Employed?*
- Yes
- No
- Retired
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Full or Part Time?*
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Name of Employer*
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How Long Employed There?*
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Are They in School?*
- Yes
- No
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Full or Part Time?*
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Adult 4
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First Name*
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Last Name*
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Age Range*
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Gender*
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Relationship To Applicant*
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Please Describe*
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Phone Number*
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eMail Address*
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Are They Employed?*
- Yes
- No
- Retired
This field is hidden when viewing the form
Full or Part Time?*
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Name of Employer*
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How Long Employed There?*
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Are They in School?*
- Yes
- No
This field is hidden when viewing the form
Full or Part Time?*
Children
Are There Children In The Home?*
- Yes
- No
How Many and What Are Their Ages?*
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How Many and What Are Their Ages?*
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Child 1
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Name*
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Age*
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Gender*
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Previous Experience with Dogs:*
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Child 2
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Name*
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Age*
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Gender*
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Previous Experience with Dogs:*
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Child 3
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Name*
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Age*
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Gender*
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Previous Experience with Dogs:*
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Child 4
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Name*
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Age*
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Gender*
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Previous Experience with Dogs:*
Dogs
Do You Currently Have Any Dogs?*
- Yes
- No
How Many?*
Have you ever taken care of a dog before (ie dog walker, dog sitter, etc) or have any other dog experience?*
If you do not currently own a pet, please list the NAME and PHONE NUMBER of the veterinarian/clinic you choose to use*
Please Describe*
Dog 1
Dog's Name*
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Where Did You Get The Dog?*
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Please Explain*
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Is Dog Still Living With You?*
- Yes
- No
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Which Years Owned?*
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How Long Did You Own Him/Her?*
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Why not?*
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Why was dog euthanized?*
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Please Describe The Situation*
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Please Describe The Situation*
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Please Describe*
Breed*
Age*
Gender*
Status*
Please Explain Why Not*
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Sociability*
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Sleeping Quarters*
Up To Date on All Vaccines?*
- Yes
- No
Vaccinated Annually?*
- Yes
- No
Up To Date On Heartworm Prevention For Every Season?*
- Yes
- No
Is There Any Additional Information You Would Like to Add?
Dog 2
Dog's Name*
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Where Did You Get The Dog?*
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Please Explain*
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Is Dog Still Living With You?*
- Yes
- No
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Which Years Owned?*
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How Long Did You Own Him/Her?*
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Why not?*
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Why was dog euthanized?*
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Please Describe The Situation*
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Please Describe The Situation*
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Please Describe*
Breed*
Age*
Gender*
Status*
Please Explain Why Not*
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Sociability*
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Sleeping Quarters*
Up To Date on All Vaccines?*
- Yes
- No
Vaccinated Annually?*
- Yes
- No
Up To Date On Heartworm Prevention For Every Season?*
- Yes
- No
Is There Any Additional Information You Would Like to Add?
Dog 3
Dog's Name*
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Where Did You Get The Dog?*
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Please Explain*
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Is Dog Still Living With You?*
- Yes
- No
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Which Years Owned?*
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How Long Did You Own Him/Her?*
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Why not?*
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Why was dog euthanized?*
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Please Describe The Situation*
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Please Describe The Situation*
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Please Describe*
Breed*
Age*
Gender*
Status*
Please Explain Why Not*
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Sociability*
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Sleeping Quarters*
Up To Date on All Vaccines?*
- Yes
- No
Vaccinated Annually?*
- Yes
- No
Up To Date On Heartworm Prevention For Every Season?*
- Yes
- No
Is There Any Additional Information You Would Like to Add?
Dog 4
Dog's Name*
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Where Did You Get The Dog?*
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Please Explain*
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Is Dog Still Living With You?*
- Yes
- No
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Which Years Owned?*
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How Long Did You Own Him/Her?*
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Why not?*
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Why was dog euthanized?*
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Please Describe The Situation*
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Please Describe The Situation*
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Please Describe*
Breed*
Age Range*
Gender*
Status*
Please Explain Why Not*
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Sociability*
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Sleeping Quarters*
Up To Date on All Vaccines?*
- Yes
- No
Vaccinated Annually?*
- Yes
- No
Up To Date On Heartworm Prevention For Every Season?*
- Yes
- No
Is There Any Additional Information You Would Like to Add?
Other Pets
Are There Other Pets In The Home?*
- Yes
- No
How Many?*
Other Pet 1
Animal Type*
Pet's Name*
Age*
Gender*
Status*
Please Explain Why Not*
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Sleeping Quarters
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Sociability
Is There Any Additional Information You Would Like to Add?
Other Pet 2
Animal Type*
Pet's Name*
Age*
Gender
Status*
Please Explain Why Not*
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Sleeping Quarters
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Sociability
Is There Any Additional Information You Would Like to Add?
Other Pet 3
Animal Type*
Pet's Name*
Age*
Gender*
Status*
Please Explain Why Not?*
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Sleeping Quarters
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Sociability
Is There Any Additional Information You Would Like to Add?
Other Pet 4
Animal Type*
Pet's Name*
Age*
Gender*
Status*
Please Explain Why Not*
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Sleeping Quarters
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Sociability
Is There Any Additional Information You Would Like to Add?

Residence
- Type of Residence*
- Please Describe Type of Residence
- Do You Own or Rent?*
- Does Landlord Allow Dogs?*
  - Yes
  - No
- Are There Any Breed Or Size Restrictions?*
- Please Provide Landlord's Name*
- Please Provide Landlord's Phone Number*
Yard Information
Do You Have A Yard?*
- Yes
- No
Is The Yard Fenced?*
- Yes
- No
How High Is The Fence?*
What Material Is The Fence Made From?*

Family & History
- Do All Family Members Want A Dog?*
  - Yes
  - No
- Please Explain Who Doesn't and Why They Don't*
- Is Any Member Of Your Household Allergic To Dogs?*
  - Yes
  - No
Are You WIlling To Take Responsibility For This Dog For The Next 10-15 Years?*
- Yes
- No
What Provisions Will You Make For The Dog Should You Become Unable To Care For Him/Her?*
- Are You Capable of Providing Timely Healthcare?*
  - Yes
  - No
- What Are You Willing/Able To Spend On Annual Vet Care?*
- Please Explain Your Circumstances*
- Have You Ever Given Up A Pet?
  - Yes
  - No
- Why?*
- What Happened To Te Last Pet You Owned? (If Deceased, How Long Ago?)*
- What are you looking for in your new family member?*
- What kind of activities does your family participate in? Will your new family member be left alone long during these outings?*
Sleep & Alone Time
- Where Will The Dog Sleep?*
- Where Will The Dog Be When Alone?*
- Please Describe Where The Dog Will Be*
What Is The Longest Time The Dog Will Be Alone (without humans)?*
- Who Will Care For The Dog While You Are On Vacation?*
- Please Explain Who Will Care For The Dog*
Behavior & Training
Dogs Can Take A Month Or Longer To Adjust To A New Home, Particularly If Other Pets Are Involved. Are You WIlling To Devote This Much Time To Make The Dog Comfortable In Your Home?*
- Yes
- No
First Personal Reference
Name*
Phone Number*
How Long Acquainted*
Second Personal Reference
Name*
Phone Number*
How Long Acquainted*
Third Personal Reference
Please Provide a Third Reference If You Don't Currently Have a Veterinarian
Name*
Phone Number*
How Long Acquainted*
Veterinarian Information
Have You Used A Veterinarian Before?*
- Yes
- No
Please Provide Veterinarian's Name*
Please Provide Veterinarian's Phone Number*
Besides your name, what other names may your pet's records be listed under*
Trainer Information
Have You Used A Trainer Before?
- Yes
- No

Reason For Adoption
Select all that apply.
Family Companion*
- Yes
- No
Personal Protection*
- Yes
- No
For Child*
- Yes
- No
Companion For Current Dog*
- Yes
- No
Replace A Previous Dog*
- Yes
- No
- Other*
  - Yes
  - No
- Please Describe Reason For Adoption*
Would You Consider:
A Mixed Breed Dog?*
Two Dogs?*
A Dog That Can Be An Only Pet?*
A Dog That Is Afraid Of Small Children?*
A Dog That Needs Medications?*
- A Dog That Has A Serious Health Condition?*
- Please Select All Health Condition(s) You Would Accept*
- A Dog Who Needs Training For A Behavior Issue?*
- Please Select All Behavior Issue(s) You Would Accept*
  Select All That Apply:
- A Dog that Has Special Needs?*
- Please Select All Special Needs(s) You Would Accept*
  Select All That Apply:
- A Dog That is Not Completely Housebroken?*
Select Gender*
Select Age Range*
Select All That Apply
Select Personality*
Select All That Apply
Select Color*
Do You Have A Preferred Dog?
Note: This does not guarantee this dog will be placed with you
List Other Dogs You Are Interested In
When Will You Be Ready To Adopt?*
Is There Anything Else You Would Like to Let Us Know?
I am interested in receiving pet related services and products*
- Yes
- No
Authorization
Authorization:*
All dogs placed through the [RecueGroupName] will have health checks, personality and temperament evaluations, and will be spayed or neutered prior to placement unless a medical condition exists, diagnosed by a veterinarian, that would prevent this surgery. I understand that this is a preliminary application and that there may be no Dog available in rescue at this time. I understand that if a Dog should become available, that I will be required to provide further information including, but not limited to, personal and veterinary references. I further understand that all information on my Preliminary Rescue Adoption Application will be kept confidential; that my application will be kept on file until I notify the [RecueGroupName] that I am no longer interested in a rescue; and that I will not be contacted unless an appropriate Dog becomes available. I understand and agree *
- I agree
Name
This field is for validation purposes and should be left unchanged.

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