ADOPTION APPLICATION

Today's Date**

Date

Name of animal interested in adopting*

Name of Applicant**

Your Address**

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Cell Phone Number**

Home/Alternate Phone Number

Date of Birth**

Email**

example@example.com

Is this your first experience with this type of pet?**

Why do you want this pet?**

What activities would you like to do with this pet? How would you provide adequate exercise & how often?*

How long have you been looking for a pet?**

Have you applied for a pet at other rescues? Were you denied by another rescue? If, so, please explain.*

Is this animal for you or someone else?**

How long have you lived at your residence?**

Home Type**

	Owned	Rent/Leased	Yes
House
Condo
Mobile Home
Apartment
Subdivison
Rural
City

If you rent, does your lease allow pets?* *

If you rent, does your lease allow for the breed that you are wanting to adopt?*

Landlord's First and Last Name*

Landlord's Phone Number*

Are there Breed Restrictions in your community?*

Do you have Homeowner's/Renter's Insurance?* *

What method of yard security you will use to keep your pet safe?**

	Yes
Chain link fence
Wood privacy
4 foot
5 foot
6 foot
Invisible Fence
Overhead Cable
Tie-Out
Leash Walk
Is this method secure NOW

Insurance Company and Phone Number**

How many people currently reside in your home?**

Please list the people residing in your home; their names, ages and relationship to you**

Do you have or expect to have frequent visitors/children/other dogs visit that you would expect the dog to interact with?*

What is you household like?**

	Yes	No
Busy (frequent visits from friends, parties, crafts, etc)
Noisy (loud TV, music, Kids playing, machinery etc)
Moderate (occasional company, normal comings & goings)
Quiet (homebodies, few guests, low activity)

Employment Status**

	Yes	No
Employed
Unemployed
Retired
Disabled

Employer's Name**

(If not employed, enter financially responsible person & identify)

Work Address*

Work City/State/Zip Code*

Employer Phone Number*

Work days per week**

Hours of employment per day**

Employer of Spouse/Partner*

Approximately how many hours a day will this pet spend alone without human companionship?**

Please list the pet(s) currently residing in your home. Please list (1) the NAME of the pet, (2) the type of pet/BREED, (3) their gender, (4) if they are SPAYED/NEUTERED, (5) if they are CURRENT ON SHOTS, on HEARTWORM PREVENTION (6) the AGE for each pet AND (7) where you obtained pet and how long you have owned him/her**

Please list any pet(s) you have owned in the PAST, other than those listed above. Please indicate the Name of type of pet, BREED, if they were spayed/neutered, kept up to date on vaccines, if they were outdoor or indoor, LENGTH OF TIME you owned the pet, and the pet's status as to what happened to them and the DATE when**

Are your dog(s) or were your past dog(s) on HEARTWORM and FLEA Prevention? If yes, what BRAND. If NO, please explain why**

Name of your Veterinarian (please CALL your vet to allow them to speak to us)**

Veterinarian Phone**

How have you disciplined your dogs in the past? What type of action was taken for behavioral issues such as barking, chewing, destructive behavior, bathroom accidents, unruly leash behaviors in your pet?*

What will you do if this pet is destructive when left alone?**

Are you ready for the high energy of some pets?**

Are you willing to attend obedience classes with this pet, if necessary?**

Who will be responsible for housebreaking, training, feeding, and overall care for this pet?*

What activities would you like to engage in with this animal?**

	Yes
Leash walking
Hiking
Running companion
Yard play
Camping
Agility
Cuddle buddy
Training
Swimming
Basic companion
Emotional support animal
Traveling

What behaviors would you not accept in a dog?**

	Yes
Getting on furniture/beds
Chewing on shoes/furniture
Shedding
Barking
Jumping on people
Digging
Rough play
Potty accidents
Fence jumping
Timid/fearful
Aggressive
Mouthiness

If you marked "Yes" to any of the above, please explain**

When home alone, where will this pet be kept?**

	Yes
Crate
Restricted area
Free Roam
Basement
Garage
Outside

What will you do with this pet when you go on vacation or if there is an emergency that takes you out of town?**

Are you planning to take a trip in the near future? If so, please explain.*

What will you do with this pet if YOU become Disabled or Die? Do you have someone designated with a plan for the continued care of your dog?**

What will you do with this pet if you move?**

Are you aware veterinary costs for this animal can become very expensive?**

How much would you expect to pay for Annual Routine Vetting (annual exam, vaccines, Heartworm testing, Heartworm/flea prevention), PLUS Basic Everyday Care...which includes food, toys, equipment, etc, for a dog?*

Are you prepared to accept financial responsibility for this pet?* *

If this pet had a medical emergency, which could exceed $2000, could you afford to provide to get the care via your funds, pet insurance, Care Credit, etc?*

Have you ever rehomed or surrendered a pet to any animal shelter? If yes, please explain.*

Have you ever been convicted of an animal related crime, such as cruelty to animals, animal theft, or animal abandonment?*

YesNo

If YES to the above, please explain

Do you or anyone in your household have any known allergies to animals?**

Is everyone in your household aware that you are planning to adopt a pet?**

Are you willing to make this adoption a PERMANENT commitment?**

Do you or anyone in the household have any physical disabilities? Are you and anyone else that would be caring for the dog physically able to care for, exercise and leash walk a dog that may have a lot of strength?*

Please list 3 personal References with name, phone number & relationship to you (please, no family members & include a neighbor if possible)**

Please provide any additional comments you might want to add to help determine approval of your application

By clicking the submit button, I agree to Streethearts Animal Rescue adoption process which will entail undergoing a home visit and interview at the discretion of Streethearts Animal Rescue.

By clicking the submit button, I give permission to Streethearts Animal Rescue to check my references which includes veterinary and personal references.

By clicking the submit button, I understand there is an adoption donation fee associated with the adoption of a pet from Streethearts Animal Rescue that is tax deductible according to IRS 501(c)3 guidelines. I understand this donation helps cover the prior medical and routine care costs of this pet which will then help enable the rescue to save and help another homeless pet. Note: Some pets we spend thousands of dollars on when they may be a victim of a medical emergency when they are rescued.

By clicking the submit button, I understand that Streethearts Animal Rescue will disclose any of the pet's health or behavior issues known to the rescue.

By clicking the submit button, I verify all of the above information is true and accurate.

Signature

Streethearts Animal Rescue Adoption Application