Rescue Dog Adoption Application

Piece Of My Heart Rescue is an all-volunteer, non-profit, animal welfare organization dedicated to the rescue and placement of stray, neglected, abused animals as well as shelter pets and owner-surrendered pets. Piece Of My Heart Rescue is completely funded through fundraising efforts and public donations. All of our pets are cared for by foster homes and receive complete medical care, which includes worming, age appropriate vaccinations, spaying/neutering, additional surgeries/treatments, flea/tick/heartworm preventative, and microchipping prior to their adoption.

This questionnaire is designed to help Piece Of My Heart Rescue and yourself determine if a specific pet is the right one for you and your household. All adopting parties are required to be involved in the completion of this form prior to adoption. (We DO NOT adopt pets out as gifts or on behalf of others such as family or friends - the individuals applying should be the pet owner.) Piece Of My Heart Rescue reserves the right to deny any adoption based on answers to this questionnaire and/or interviews prior to adoptions. Filling out an online application does not guarantee automatic adoption. In the case of multiple applications, we will chose the application that best aligns with the pet's needs.

Name of the pet you are interested in: *

Your full name: *

Street Address: *

City, State, Zip *

Home Phone:

Area Code Phone Number

Work Phone:

Area Code Phone Number

Cell Phone:

Area Code Phone Number

E-mail:

Employer:

Character reference and phone number:

Are all members of your household in agreement with this adoption? *

Yes No Don't Know

List NAMES and AGES of all human members of your household:

Who will be the pet's primary caregiver? *

Do you live in a *

House Apartment Condo Mobile Home Patio Home

Do you own or rent? *

Own Rent

If rent, provide name and phone number of landlord:

Does your landlord allow dogs?

Yes No I don't know

Are there any restrictions from your landlord or subdivision?

Number of pets Species of pets Size or weight restrictions Breed restrictions None I don't know

Do you have a fenced yard? *

Yes No

Fully or partially?

Height and type of fence:

Do you have any of the following?

Underground fence Outdoor kennel Indoor/Outdoor dog run

Have your children been around animals before?

Yes No

Are any of your children afraid of/do they react to pets for any reason?

Yes No Don't know

Does anyone in your home have allergies to dogs or have asthma? *

Yes No

Have you PERSONALLY owned any pets in the past?

What breeds and how long did they live?

Do you currently own other pets?

List names, species, breed, age of each:

How many of your current pets are spayed/neutered?

Have you adopted from an animal welfare group before?

Yes No

If yes, what group?

Have you ever given up a pet?

Yes No

If yes, what were the circumstances?

Please provide the name and phone number of your current and/or previous veterinarian or clinic:

Please provide the name and phone number of your current and/or previous groomer:

What type of personality do you want your pet to have? (i.e. calm, energetic, protective, couch-potato) *

How do you feel about dog crate training? *

I think they're cruel. I crate my dogs for their mental stability throughout their life. I crate in the beginning but as the dog gets accustomed to my home I'll wean the dog away from it - my goal is to have a dog loose in my house eventually. I will do whatever this dog needs.

Have you ever house-broken a dog or puppy before? *

Yes No

If the dog has an "accident" in your home, what type of correction do you plan to use? *

How many hours each day will your new pet be home alone? *

Where will your pet be kept while you're at work and/or not at home? *

Where will your new pet sleep at night? *

How will you supervise the dog's outdoor activity? *

How often do you have visitors to your home? *

Will you take your dog to the dog park? *

Will you take your dog to dog daycare? *

What length of time will you allow your new pet to adjust to their new home? *

What food do you plan on feeding? *

What is your feeding routine like in your home? *

Feed twice a day Feed once a day Keep food bowl full so the dog can graze when hungry

Are you willing to work through your new pet's issues, if any? *

Yes No

Are you willing to adopt an older pet? *

Yes No

Did you read the bio of this pet thoroughly? *

Are you willing to adopt an abused pet? *

Are you willing to adopt a pet that is unreliable with children? *

Are you willing to adopt a pet that requires medications, supplements, and/or special diet? *

Are you willing to adopt a pet that is/could become handicapped? *

Would you take the dog to training if needed and complete the class? *

Are you familiar with the breeds of the dog for which you are applying? *

Are you aware that rescue pets can have health and/or behavior issues? *

Do you understand that a dog can be an 18 year commitment, and can cost $300 - $500 per year to care for? *

Yes No

If the pet required a $1,000+ surgery or treatment, would you go through with it? *

Do you plan to take an obedience class with your dog? *

Yes No Not sure

If yes, where?

Are you aware that a large breed dog takes about two years to mature? Is this something for which you are prepared? *

Yes No Not applicable to this pet

What circumstances would lead you to give up your new dog? *

If you had to give up your dog, what would you do with him/her? *

Why do you want to adopt at this time? *

How did you find out about All Piece Of My Heart Rescue? *

Adoptapet.com Petfinder.com Facebook Friend/Family Member Other website PetSmart

I understand that I assume full responsibility for the welfare of this pet from the date of adoption.

Piece Of My Heart Rescue Adoption Application

Applicant Information

Household Information

Current/Previous Pet Information

New Pet Information