EmailMe Form - BRLA Adoption Application

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Please confirm email

Home Phone *

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Work Phone *

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

Cell Phone *

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Occupation *

How did you hear about BRLA? *

Personal Reference *

First Last

Personal Reference Phone *

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Relationship to Reference *

How many years acquainted? *

Have you ever rescued a pet before? *

Yes

No

If yes to previous rescue, please describe

Residence: *

House

Apartment

Condo

Other

If Other, please explain

Do you Own or Rent/Lease? *

Own

Rent/Lease

If Rent/Lease, I can provide landlord proof of approved pet policy

Yes

No

Our residence has a yard *

Yes

no

The yard fence height is *

The lowest point of our yard fence is *

Our yard fence is constructed of (select all that apply)

hold down control key for multiple choice

Is your yard completely secure?

Yes

No

If not secure, please describe

Do you have a swimming pool? *

Yes

No

Is your swimming pool securely fenced off

Yes - fully secure

Yes - partially secure

No - not fenced off

How many adults live in your home? *

Children in the home? *

Yes

No

If Yes to Children in the home, please list ages

Please describe what exposure your children have had to dog in or out of your home.

Who will be main caregiver to new Boxer? *

Do you currently have another dog(s) at home? *

Yes

No

If Yes to other dogs at home, please describe, breed, gender and age:

Are other dogs in home spayed/neutered? *

Yes

No

No other dogs in home

If not spayed/neutered, please explain

If Yes to other dogs, please describe temperment of dogs in your home

If Yes to other dog(s), do they socialize with other dogs outside your home

Yes

No

If yes to socializing with other dogs outside home, describe other dogs and type of activities they engage in.

If your current dog does not socializing with dogs outside your home, please explain.

Do you have a cat or cats? *

Yes one cat

Yes multiple cats

No cats

If you have cat(s) where do they live

Indoors

Outdoors

Indoors & Outdoors

Do you have any other pets / livestock? *

Do you plan to walk you Boxer daily *

Yes

No

If you do not plan on walking your Boxer, please explain

How will your new Boxer get exercise *

Your Veterinarian: *

Your Vet's Phone

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

How many dogs have you owned in the last 5 years? *

What happened to other dogs? *

Have you owned a Boxer(s) before *

Yes

No

Dogs outside your home (friends/family) that will interact with your new Boxer *

I want to adopt a boxer as a: *

Why do you want to adopt a Boxer? *

What do you like best about Boxers: *

Are you ready / willing to provide training for your new Boxer? *

What training methods are your familiar / comfortable with? *

When will you be ready to adopt? *

I would prefer to adopt this gender *

Male

Female

No Preference / Best Match

If you selected a specific gender, would the opposite sex be a deal breaker even if perfect match otherwise?

Not a deal breaker - I would consider if great dog

Yes I only want the gender I specified

I prefer this color Boxer *

Fawn

Brindle

White

No preference / best match

If you selected a particular color preference, is there any color that would be a deal breaker, even dog was perfect match otherwise?

I prefer these attributes: *

If you selected cropped tail would a natural tail be a deal breaker if it were on the perfect match otherwise?

Not a deal breaker - would consider if great dog

Yes I only want a cropped tail

What age range best fits your family and lifestyle? *

Are you interested in any particular dogs currently on our website?

Where will your new Boxer spend most of the day *

How much time will your new Boxer spend in the house with family each day? *

How many hours will your new Boxer be without a human home each day? *

Where will your boxer be when left alone? *

Where exactly will your new Boxer sleep at night? *

How will you discipline your new Boxer? *

Your leadership skills with dogs? On a scale of 1 - 10 (10 being strongest leader and 1 being just love) what is your pack leadership level? *

What issues would cause you to return an adopted Boxer? *

Will you license your Boxer and keep license current *

Yes

No

Are you capable of providing timely healthcare for your new Boxer? *

Yes

No

If you cannot provide healthcare, please explain:

In the event you are no longer able to care for your new Boxer, you will return to BRLA *

Yes

No

I will allow a BRLA representative to visit for a home check *

Yes

No

Additional comments:

I declare that all statements provided on this form are true and complete to the best of my knowledge. *

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