EmailMe Form - Adoption Application Jr HS

Name *

First Last

Your Age (applicants must be at least 21 years of age) *

Co-Applicant Name, age, & relation to primary applicant

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Email *

Home Phone

### - ### - ####

Cell Phone *

### - ### - ####

Work Phone

### - ### - ####

Applicant Employer and Occupation

Applicant Work Schedule

Co-Applicant Employer and Occupation

Co-Applicant Work Schedule

How many hours per day will the dog be home alone without the PRIMARY ADULT applicants?
(We do not consider children as caretakers for the dogs.) *

What provisions will be made for the dog during these hours?

How did you hear about us?

Why do you want to rescue a dog?

What is your time-frame for adoption?

Age range of dog you would like to adopt *

Gender preference?

Preferred or required?

Dog size preferred *

Energy level desired *

Which of the following would you consider? *

Would you be interested in adopting a bonded pair?

List in order of importance the characteristics you want in a dog

Have you ever owned a dog as an adult?

List details about the dogs you have owned. Include the approximate date range that you owned each dogs.

Which dogs are with you presently.

What is your experience with rescued dogs?

Indicate your level of training experience.

Where do you plan to enroll your next dog for obedience training? This is highly recommended for rescued dogs and may be required of some dogs.

Do you own any other pets?

If yes, list details about those pets.

Are all pets spayed/neutered?

Are all pets up to date on vaccinations?

Current vet's name, address, phone number. *

Have you ever had a pet who became lost?

Have you had a pet poisoned?

Have you ever had an animal killed by a vehicle?

Have you ever had an animal treated for a disease?

Have you ever sold, given away, or surrendered a pet to a shelter?

IF YES, TO ANY OF THE ABOVE, PLEASE EXPLAIN IN DETAIL (YOUR APPLICATION MAY NOT BE CONSIDERED FURTHER WITHOUT ADEQUATE DETAIL)

Do you live in a house, apt, condo, etc?

Is there a second home that the dog would frequent? If so, give details & location of second home. (ie - vacation home, home of other parent)

Do you rent or own?
If you rent, give landlord contact info.

If you rent, do you have permission to keep a large dog?

Do you have a yard?

What is the size of your yard?

Is all or a part of your yard fenced?
If a part is fenced, is it attached to the house and fully enclosed?

Type of fencing - physical (style, height), invisible, etc.

If no fence or partial fencing, how will your dog will be allowed to exercise, play, and relieve him/herself while being kept from running away, getting lost, or getting hurt? (be as detailed and specific as possible – describe HOW you plan to do this?

How will your dog be exercised and how often do you plan to provide this exercise?

What will you do if your dog needs more exercise than you planned?

How often and under what circumstances will your dog be left unattended outside?

How often and under what circumstances will your dog be allowed to be off-leash in unfenced areas?

Do you have a tie out or runner for your dog?
If, yes, explain in detail how and when it is used.

Other than the applicant(s), how many adults in the household and relationship to applicant(s)?

How will they be involved in the care of the dog?

How many children in the house?

What are the children's ages?

Level of children's exposure to large dogs?

Who will be responsible for the care of the dog?

Who will be responsible for the training?

Where will the dog be primarily kept?

Where will the dog be kept when no one is at home?

Where will your Golden sleep?

Is anyone in the household allergic to dogs? To other animals?

How often do you travel?

Who will care for your dog when you are away?

Are you planning to move in the near future?

When you do move, what will you do with your dog?

Does everyone in the household want to adopt a dog?

Please use this space to tell us anything about you which you think may be helpful. Please remember, only the best applications are selected for our Goldens—here is your chance to tell us why yours is one! *

What dog are you interested in adopting?

If you agree to each of the following, indicate "yes." If you do not agree to all, indicate which you do not agree to. *

Your rescue dog will be kept on heartworm prevention for the first 12 months you have him/her, and as recommended by your vet thereafter.

By submitting this form I hereby authorize a representative to verify all information provided on this form and give our veterinarian permission to disclose all medical information requested by a rescue representative.

The applicant will agree to not use a tie-out, runner or leave the rescued dog unsupervised when outdoors - which includes the use of a doggy door.

The applicant agrees to leashing the dog at all times in unfenced areas.

All of the information I have given in this questionnaire is true and complete. Should a rescue animal be placed with me, it will reside in my home as a pet. I agree to provide all necessary veterinary care, food, shelter, and love.

Is it understood that we reserve the right to remove a dog at any time should we find the adopter is no longer caring for their Golden in a way we see fit?

Are you willing to travel over 2 hours to pick up your dog?

Are you willing to allow a rescue volunteer to complete a home visit in order to approve adoption? We also require adopters to agree to follow up visits as needed.

By entering my signature here, means I have agreed to all the terms in this form and agree that directors, officers, and volunteers of the rescue group.

It is understood that submission of this application DOES NOT guarantee a dog will be placed with you.

Name *

First Last

Date Time *

MM / DD / YYYY