ADOPTION APPLICATION

Name:
Age:
Name of Spouse:
Email Address:
Street Address:
City:
State:
Zip:
Home Phone No:
Cell Phone No:
What dog are you interested in adopting?
Why do you want to adopt this dog?
On a scale of 1 (quiet) to 5 (high energy)...what activity level are you looking for? 1
2
3
4
5
Will you consider another dog if this one is not available or if we do not think this dog is a suitable match for your family? Yes
No
If yes, please specify: (Age range, sex, breed)
Would you consider a special needs dog? Yes
No
Employer:
Employer Phone No:
Number of adults in home:
Number of children living at home: None
1
2
3
4
5+
What are ages of children:
Do you have young children visit on a regular basis? (i.e., grandchildren, babysitting) Yes
No
If yes, what are their ages:
Other than immediate family list all others living in your home and their ages:
Is everyone in your home agreeable to adopting a rescue dog? Yes
No
How long have you lived at this address? 0-1
2
3
4
5
6
7+
Previous address if less than 2 years:
How many years at previous address:
What type of housing do you live in:
Do you: Own
Rent
If you rent, what is Landlord's Name:
What is Landlord's phone no:
Social Environment: City
Suburban
Country
Does your home have a backyard? Yes
No
Is backyard fenced? Yes
No
Describe fence type and height:
Is edge of fence buried to prevent tunneling? Yes
No
If no fence, how do you plan on taking the dog outside?
Explain specifically what the dog's living situation will be: (Ex: run of house, basement, outisde, kennel, etc.)
How many hours will dog be left alone during the day? 1
2
3
4
5
6
7
8
9+
Describe specifically where the dog will be kept when home alone:
Are you willing to spay/neuter this dog? Yes
No
If no, why not?
How long do you plan to keep this dog:
Under what circumstances would you give this dog up?
Do you currently own any pets? Yes
No
If yes, please list breed/age/sex:
Are your current animals spayed/neutered? Yes
No
If not, explain the reason that they are not spayed/neutered:
Are your current animals up to date on all shots? Yes
No
If not, why not?
Approximate date of last Veterinarian visit for each current pet:
Have you ever given a pet away? Yes
No
If yes, explain your reason:
List other pets you have owned in the last 10 years (not mentioned above) and what happened to them:
Veterinarian Name:
If account is not under your name, please list name account is under:
Veterinarian Phone No:
Do you understand that even though a dog may be housebroken in their foster home, when they move to a new environment there is an adjustment period where they may have accidents in their new home? Housebreaking techniques will need to be utilized. Yes
No
What type of potty training methods will you use?
Are you planning on enrolling the dog in obedience class? Yes
No
If needed
List any Breed, Humane Societies, rescue organizations, training clubs and similar organizations or memberships: (If none, type "none")
Do you understand that often times the complete history of a rescued dog may not be known: Yes
No
Will you be willing to work with us to correct any possible behavior problems after adoption? Yes
No
Please provide name, address and phone number of two references and their relationship to you. If you have a groomer, please use them as one of your references. Please limit references to only one family member. (Please contact your references and notify them that we will be contacting them.)
I declare that I am financially and physically able to care for a rescue dog. Yes
No
I understand that proper food, grooming and veterinarian care may be costly and I am able and willing to meet the needs of my adoptive dog. I understand
I do not understand
I grant permission for home checks at random both prior to and following adoption. Yes
No
I understand that if a home check reveals falsification or misrepresentation of any facts on my part, Maple Hill Farm Toy Breed Rescue reserves the right to either refuse adoption or to nullify the adoption and reclaim said rescued dog from my premises without reimbursement of the adoption donation. I understand
I do not understand
I release Maple Hill Farm Toy Breed Rescue from any liabilities I may incur from the adoption process. Yes
No
I understand by submitting this application, I am declaring that the information I have provided in this application is complete and correct. Yes
No

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