Adoption Form

Name of dog you wish to adopt *

Your Name *

Your Email *

Your Phone *

Your Address *

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Your Age *

Marital Status *

Occupation(s) *

Employer *

Work Phone Number *

Working Hours *

How did you hear of us? *

Do you have a fenced in property? *

YesNo

Have you applied with another rescue for a dog? (If so who and when)

What type of living quarters do you reside? *

Do you own or rent? *

Would you allow us to make a home visit? *

[radio* home_visit use_label_element default:1 "Yes" "No"]

How many adults live in your household and what is their relationship to you? *

How many children are in your household, their relationship to you, and their ages? *

How often do children visit you? (Including grandchildren) *

Are you planning to have children & how soon? *

Do any people in your household or regular visitors have allergies? *

Do you or anyone in your home have health issues that would keep you from giving the dog a lifetime home? *

Describe your lifestyle (hours home, busy, etc.) *

Will your pet be included? *

How many hours a day will your pet be left alone? *

How much time will you be able to give your pet on a regular schedule or day? *

When your pet is left alone, where will you keep him/her? *

Where will your pet sleep at night? *

Have you ever given up a pet? Why?

How will you exercise your pet? By who? *

Who will be responsible for the care of your pet? *

Under what conditions would you give your pet away? *

Where will the pet stay when you're on vacation or away? *

Where would you take your pet if you no longer were keeping it and why? *

What would you do to correct behavior that is unacceptable? Have you done this in the past? *

Will your pet be allowed on furniture? *

Please list any current or past pets in the last 10 yrs and their ages, breed, neutered/spayed, sex, and size. *

Please list the vets you have used in the past (Name of Vet, Phone Number, Name of Practice, Location) *

Can we contact your vet for a reference? Would you still use the same vet? *

If your pet(s) are no longer with you, why not? *

Do you give your pet heartworm medication? *

If so, what brand and where do you buy the medication?

Do you have your pets on flea/tick control? *

If so, what brand and where do you buy the flea/tick control?

What brand of dog food do you feed and why? *

Would you give your new pet 2 months for an adjustment period? *

Will you accept a dog that is not housebroken and why? *

What would you do to correct the following:

Barking *:

Pee Pee on floor *:

Shyness *:

Snapping out of fear *:

Chewing *:

Owning a cocker you are required to groom your pet every 6 to 8 weeks. Does this present a financial problem? Grooming is approximately 40 dollars every 2 months. *

Are you committed to giving this pet a forever home? *

Do you have any additional comments or questions? *

Have you had any previous experience with owning a cocker? Tell us what if any. *

Do you have a fenced yard? If so what kind and size? *

Please add three references (Name, address, phone and relationship).

1st reference *

2nd reference *

3rd reference *