Adoption Application

Please remember that our intent is not to be intrusive. We simply want to find the best match for you and our terriers. If you have any questions, please ask. We are happy to help.

The completion of this application is a must for adoption!

Although this dog has received excellent care while here, it is the nature of rescue work that not everything about the history or status of the animal can be known.

I recognize that handling this previously stray/rescue animal(s) may place me and/or others with me at risk for being scratched or bitten.

I understand the risks inherent in handling any previously stray/rescue animal.

I agree to indemnify and hold harmless the Coastal Jack Russell Rescue, its officers, directors, employees agents, and representatives from all manner of actions and causes of actions, suits, debts, dues, accounts, bonds, covenants, contracts, agreements, judgments, claims and demands whatsoever arising out of my possession and placement of this animal.

I also understand that the Coastal Jack Russell Rescue will not be responsible for any medical care (or cost thereof) required after placement of the animal.

In addition, the Coastal Jack Russell Rescue cannot be held responsible for the conduct, behavior, or disposition of this dog after its placement.

If you would prefer to work with a printable version of the adoption application, please choose the appropriate link below:

adoption application (pdf format requiring Adobe Reader)
adoption application (doc format requiring Microsoft Word)

To complete our adoption application online,
please fill out and submit the form below.
By completing and submitting the application below,
you agree to all terms and conditions listed above.

Do you agree to all terms and conditions listed above?
Yes
No

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Email Address:

Home Phone:

Work Phone:

Cell Phone:

When is the best time to reach you
and at which telephone number?

Occupation(s):

Do you own or rent your home?
Own
Rent

If you rent, do you have the
landlord's permission to keep a dog?
Yes
No

Landlord's Name:

Landlord's Phone Number:

Do you live in a:
House
Apartment
Mobile Home
Other

If you answered 'Other', then please describe:

How long have you lived at this address?

Do you have a completely fenced yard
suitable for a dog?
Yes
No

Do you have a kennel run?
Yes
No

Describe fence or kennel run
(type, height, size):

If there is no fence or kennel run,
how will you handle the terrier's
exercise and toilet needs?

Do you have a suitable dog crate?
Yes
No

How many adults in the household?

Please describe the age and gender
of any children in the household:

Are any menbers of your household
allergic to animals?
Yes
No

How many hours a day would the
the terrier be alone?

Are there other visitors to your home,
human or animal, with which a new dog
will have to interact?
Yes
No

Please describe your lifestyle:
Active
Passive

How did you learn of Coastal
Jack Russell Terrier Rescue?

Do you own other dogs?
Yes
No

If so, please list breed,
size, and gender of each:

Are all of your dogs spayed or neutered?
Yes
No

Are all of your dogs current on all
vaccinations and regularly receiving
heartworm preventative?
Yes
No

If you answered 'yes' to above,
please state the brand of heartworm
preventative:

Do you own cats?
Yes
No

If you answered 'yes' to above,
please tell us how many cats you have:

Please list the types of any
other animals you own:

How many dogs (or other pets)
have you owned during the past
five years?

If you do not still own the dog(s)
(or other pets), describe what became
of it (them). Please be specific:

Have you owned a Jack Russell Terrier before?
Yes
No

Why are you considering this breed?

What activities do you plan with this dog (if, any):
Pet
Guard
Hunting
Obedience
Flyball
Agility
Attending JRTCA terrier trials
Other

Do you intend to keep this dog:
Primarily indoors
Primarily outdoors

Where would this dog sleep?

Do you have a regular veterinarian?
Yes
No

Veterinarian's name:

Veterinarian's address:

Veterinarian's phone number:

Tell us what kind of dog you are
looking to adopt (male/female, age,
etc.):

Would you be willing to consider a
suitable dog of a different:
(check any that would apply)
Sex
Age
Breed
Size
Other

Name of Personal Reference:

Relationship of above named personal reference:

Phone number of above named personal reference:

Comments or questions that you might have:

Coastal Jack Russell Terrier Rescue
For more information email: JumpinJackRescue@gmail.com