Pre-Screening Adoption / Foster Form

Name:

Address:

City:

Postal Code:

Telephone: Home:

Cell:

Business:

E-Mail Address:

I agree that the animal is being adopted for myself , will not be sold, adopted, or given away:
yes
no

I agree that the animal will not be allowed outdoors without proper supervision and control:
yes
no

I agree that this dog is to be a companion animal, not a guard dog. The dog will live inside my home:
yes
no

I agree to care for the animal in a humane manner and be a responsible animal guardian:
yes
no

I agree that if at any point I can not keep the animal, I will return him/her to the original rescue:
yes
no

I understand and agree that the current rescue makes no guarantees about the animal's temperament:
yes
no

I agree to keep the rescue informed of my current home address and phone number:
yes
no

Number of adults in the home, ages:

Occupations of caregivers:

Number of children, ages:

Is anyone allergic to animals:
yes
no

Who will be responsible for this animal?:

Type of dwelling:

Own/Rent:

If renting, landlord?s name and phone number:

If renting, does your landlord/rental agency allow pets:

How long have you lived at your present address:

If you move sometime in the future, what will you do with your pets:

Do you anticipate moving within the next six months:

Do you presently have any pets:
yes
no

How many:

If yes, please provide the following information on your animals, Name, Breed, Age, Sex, S/N:

Will this/these pets accept a new dog into your home:
yes
no

Are you willing to work with both your present pets and a new dog to make an addition work:
yes
no

Are all your pets current on their vaccinations:
yes
no

Current Veterinarian/ Clinic, Name and #:

Have you ever given up an animal:
yes
no

Reason:

Have you ever had animals pass away from un-natural causes:
yes
no

Reason:

Are you financially able to care for this dog including emergency medical care:
yes
no

Approximately how many hours per day will the dog be left alone:

Where will the dog be when you are not home(ie. crate/room/loose):

Do you have a fenced yard secure for a dog:
yes
no

How do you plan on exercising the dog? Please give details:

Have you had a dog in the past:
yes
no

How many years ago, what happened to the dog:

Breed(s):

Have you ever taken obedience training courses/when,what method:

how will you deal with problems. such as digging, chewing, barking, or separation anxiety:

Are you willing to housebreak a dog:
yes
no

Would you be willing to foster a dog:
yes
no

Please provide a reference(not family)name, #, relationship:

Are you inquiring about a specific dog we have for adoption:
yes
no

What breed/name:

Are you willing to go on a waiting list for another dog:
yes
no

What are you looking for:

The information I have given is true and complete to my knowledge:
yes
no

Sign:

Date:

Please type the text below: