Adoption Application
Please complete the form below to start the process of becoming an approved adopter with Miri's Haven Senior Dog Rescue. PLEASE NOTE: Primary adopter must be at least 21 years old - We DO NOT place dogs on a first come, first serve basis - Thorough veterinary reference checks will be done and vaccines and preventatives are required - A home visit or virtual tour is required - We do not permit the use of an invisible fence with our dogs - We do not adopt to homes that welcomed a new dog in the last 6 weeks or plan to adopt again within 6 weeks
Date
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-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Co-Adopter name (if applicable)
First Name
Last Name
Which dog(s) are you interested in? Please list all dogs you would consider, as availability may change:
*
If the above listed dogs are longer available would you still like to continue with the application process to be pre-approved?
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Yes
No
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number
*
Secondary Phone Number (if applicable)
Can we text you at the number(s) above?
*
What Type of Home do you live in?
Apartment/Condo
Towhouse/ Rowhome
Single Family/ Detached Home
Other
How long have you lived at this address?:
*
Do you own your own home?
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Yes
No
Live with
Name and phone # of landlord or property management company:
*
Does your landlord have pet restrictions? If so, what are the restrictions?
*
Occupation:
*
Name and age of ALL occupants in household (including yourself):
*
Please list all residents of the home, age and relationship to adopter
If no children, do you plan on having children or will children be visiting the household frequently?
*
Yes
No
Are any members of your household allergic to animals?
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Yes
No
If yes, please explain:
*
Over the past 5 years, how many pets have you owned? (Include current pets)
*
Please Select
0
1
2
3
4
5
6+
List Current Pets or most recent pets name, age, breed
*
Are your pets spayed or neutered?
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Yes
No
N/A
My pets are current on the following; Please check all that apply
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Annual Wellness Exam
Heartworm and Tick-borne illness test
Heartworm, flea and tick preventatives (heartgard, frontline etc)
Rabies Vaccine
Bordatella Vaccine
Distemper Vaccine
Other
If not current, please explain:
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Will you provide your dog with monthly heart worm/flea/tick prevention?
*
Yes
No
What brand pet food do you feed your pets?
*
Quality nutrition is vital for a healthy senior dog!
If you currently own a dog or cat, how does he/she react to new pets? Have they had another pet share their home?
*
Have you ever lost or rehomed a pet?
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Yes
No
If yes, please explain:
Do you have a fenced yard?
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Yes
No
How tall is your fence?:
*
Do you have a dog door leading outside?
*
Yes
No
Do you have locks and/or latches on all your gates?
*
Yes
No
N/A
Do you have a pool or hot tub? If yes, please describe any fencing or security features:
Tell us about your typical schedule, both weekdays and weekends: How often will your new pet be left alone?
Where will the dog be kept when alone?
*
Will your new dog receive walks regularly? If no, please explain:
*
Will you be able to provide a new dog socialization, play-time (if applicable) and enrichment activities?
*
Where will your dog sleep?
*
If your dog displays behavioral problems (such as jumping on people, excessive barking, potty accidents, etc.) how would you go about correcting the behavior?
*
Contact a Professional
Use a book
Personal Knowledge
Other
If other, please explain:
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Do you have experience caring for senior and special needs dogs?
Are you planning on moving in the next year
*
Yes
No
If yes, what are your plans for your pet(s) if you move?
What plans do you have for your new pet when you are on vacation?
*
Is your entire immediate family in agreement with the decision to bring a new pet into your home?
*
Yes
No
If adult co-adopters, what would your plan be if the relationship were to end?
Have you or any member of your household ever been charged with cruelty to animals or negligence in animal care?
*
Yes
No
If yes, please describe:
*
Name of Veterinary Office where recent pets are seen:
*
We will call for a veterinary reference check
Veterinary Practice Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Veterinarian Phone Number
I acknowledge and consent to Miri's Haven volunteers contacting my veterinarian. Understand that we cannot process your application if consent is not given.
*
Yes
No
Please provide 2 personal references (cannot be a relative) that can testify to your responsibility and ability to care for your animals and has been to your home. This is required or your application cannot be approved.
Reference #1
*
First and Last Name & Relationship to Self
Reference # 1 Phone Number
*
Reference #2
*
First and Last Name & Relationship to Self
Reference #2 Phone Number
*
Do you plan to welcome an additional person and/or pet into your home in the next 6 weeks, or have you welcomed a pet into your home in the past 6 weeks? If yes, please explain:
*
Are you currently working with other rescues to find a dog or have you applied with any other shelter or rescue organization in the past year? If so, what was the outcome?
*
Please upload a picture of your drivers license or ID
*
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If there is anything else you think we should know, please note it here:
How did you hear about us?
Please verify that you are human
*
Signature
We are an all volunteer rescue. Please be patient as it may take us a few days to reply by email to your application.
Thank you for your interest in adopting a senior dog!
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Submit Adoption Application
Submit Adoption Application
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