Dog Adoption Application Form Contact Information Full name: Occupation: Address: How long at this address: _ Daytime Phone: Evening Phone: Best time to call: Email address: Family & Housing How many adults are residing in your home (their relationship to you)? How many children (ages)? What type of home do you live in single family, town home, apartment, farm, etc.? Please describe your household: Active Noisy Quiet Average If you rent, please list the rules governing pets and the landlord s name and number: (by providing this information you are allowing SCDR to contact your landlord please inform them of this call so they will speak with us) Does anyone in the family have a known allergy to dogs? Is everyone in agreement with the decision to adopt a dog? 1
Do you have time to provide adequate love and attention? Other Pets Have you owned/adopted a dog before? : Yes No What other pets do you have (specify type and number)? Are these pets up to date on vaccines? Are these pets spayed/neutered? If not..why? Have you ever surrendered a pet? If so, why? Have you ever had a pet euthanized? If so, why? Have you ever lost a pet to an accident? How do you discipline your pets and why? Lack of adequate training is one of the most common reasons that dogs wind up in shelters. Are you willing to enroll your dog in obedience training classes to prevent this from happening? Do you already have a trainer in mind (provide name)? Veterinarian Do you have a regular veterinarian? Yes No Veterinarian s name: Clinic Name: Clinic Address: Clinic Phone: (By providing SCDR with this information you are allowing SCDR to call your vet. Please call your vet and ask them to authorize the release of information to SCDR.) 2
About the Dog You Wish to Adopt Dog interested in: What is your idea of an ideal dog and why? Desired age: Desired Size: Desired breed: Breed you would not adopt: Desired sex: Spayed Female Neutered Male No preference Willing to adopt: outgoing/hyper dog shy dog dog that needs regular medication dog that needs training dog that needs grooming None of these Where will the dog spend the day? (describe) Where will the dog spend the night? (describe) Number of hours (average) dog will spend alone? Who will have primary responsibility for this dog's daily care? Who will have financial responsibility for this dog? Are you aware of and prepared for the financial obligations of owning a dog (food, routine vet care, heartworm and flea/tick prevention medications, yearly examination and vaccinations, obedience training etc.)? Yes No Do you agree to provide regular health care by a Licensed Veterinarian? Yes No Do you agree to keep the dog as an indoor dog? Yes No Dogs require regular exercise to prevent boredom induced negative behaviors. When the dog goes out, how do you plan to exercise and supervise it? Fenced yard? Do you agree to contact SCDR if you can no longer keep this dog? Yes No Are you be willing to let a representative of SCDR visit your home by appointment? Yes No 3
How did you hear about SCDR? Would you be interested in fostering? Yes No Would like to know more Personal References Please provide at least two personal references, preferably your dog trainer, pet sitter, groomer or someone who knew your previous dogs or if you re a first time dog owner, the name of someone whose dog you have cared for. Include their name, telephone # and how this person knows you and your ability to provide a good home for a dog: Name: Address: Phone: Relationship (relative, neighbor, friend, etc.): Name: Address: Phone: Relationship (relative, neighbor, friend, etc.): All of the information I have given is true and complete. This dog will reside in my home as a pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccinations under the supervision of a licensed Veterinarian. (Signature) (Date) 4
Please read the following! To be considered as an adopter, you must: Be 21 years of age or older. If you rent your home you must have consent from your landlord to have a dog. Have all dogs and cats in the home spayed or neutered, if they are 6 months or older, unless there are medical reasons for not doing so. Have all dogs in the home up to date on vaccinations. Agree to have a home visit done by one of our volunteers. The volunteer will need to see the area of the home where the dog will be allowed and also visit with family members and current pets. Distance is a factor in whether or not the required home visit can be completed. We are a 100% volunteer run organization. Although we do have volunteer contacts in many areas, some areas may be difficult for us to locate a volunteer to conduct the home visit. We will let you know ASAP if your application needs to be denied due to our inability to find a volunteer to conduct the home visit. You must also agree to the following conditions, which are included in the adoption contract: If adopting a puppy, agree to follow up with SCDR to ensure spay/neuter within 1 month of adoption or the date specified on the adoption contract (at age 6 months for puppies). Be able and willing to spend time/money necessary to provide training, medical treatments and proper care for the entire lifetime of the dog. Provide the dog a collar and nametag to be worn at all times. Never allow the dog to be unleashed when on public streets, parks, etc., and never transport in the back end of an open truck without proper harnessing. Allow dog to sleep indoors and be part of the family. Never allow dog to be left unattended with young children. Our rescue organization is an all (unpaid) volunteer organization. For each application we receive it takes us approximately 3 hours to review, contact all personal and veterinary references, and make a decision on approval of it. Depending upon volunteer availability, this can take us several days to accomplish, especially when we receive many applications or if we have difficulties reaching references. An approved application means that the applicant is approved to adopt a dog from our organization; it is not a guarantee that the applicant will be allowed to adopt the dog specified on the application. We often receive many applications for small dogs, so please don't be too disappointed if your application is approved but another approved applicant is selected to adopt the dog. We strive to do our best, and always take the best interest of the dog into consideration. 5