Adoption Application

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Driver license number and issuing state*

Employer Name*

Employer Address*

Employer Phone Number

Please enter a valid phone number.

Number of Years at This Employer*

Please provide the name and contact information for 2 personal references. *

Have you adopted from us before?

YesNo

If you answered yes to the previous question, please provide details. i.e. pets name, when was the adoption?

Is there a dog in our care that you are interested in adopting? If so, please tell us which one.

Why are you interested in adopting this particular dog?

Please provide details about the type of dog you are looking for. (Size/weight range, sex, breed, personality) *

In what type of home do you live? (Single family, apartment, townhouse, condo, farm)*

Single familyApartmentCondoMobile Home

Do you own or rent your home?*

OwnRent

If you rent, please provide your landlord’s contact information. (Name, address, phone, email) By providing this information, you consent to our contacting the landlord and them providing us with information about your pet policy.*

Please list the names and ages of all occupants in the home.*

How would you describe your household?*

Do you live in an area with Breed Specific Legislation (BSL), an HOA contract, apartment, county or city that prohibits, restricts or requires registration for ownership of any specific dog breed?*

YesNo

If you answered yes to the previous question about breed restrictions, please explain what breed restrictions apply to you and who enforces these restrictions.

Do you have a fenced yard?*

YesNo

If you have a fenced yard, how high is the fence and what type of fencing do you have? (Privacy, chain link, smallfarm animal fencing, barbed wire, etc? )

Are you willing to let a representative visit your home by appointment?*

YesNo

Where will the dog live and sleep? (In the home, In a fenced yard with a doghouse and adequate shelter from weather, etc)*

How long will the dog be left alone at any given time?*

Where will the dog stay while you are away? Check all that apply.*

Indoors in a crateIndoors in a room with a barrierFree roaming indoors (with a doggie door).Free roaming indoors (no doggie door)In a fenced yard with adequate protection from weatherAt a boarding facility or doggie daycareOther

When the dog goes out, how will they be supervised?*

Does anyone in the family have any known allergies to dogs? *

Are there any other pets in the home? If yes, please list names, ages, sex and breed*

If you have other pets, are they spayed or neutered?*

Yes, all are spayed/neuteredSome, but not all of them are spayed/neuteredNo, none of them are spayed/neuteredN/A

Are your other pets on heartworm preventative and up to date on vaccinations?*

YesNo

Please list what type of heartworm preventative you use.

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

Have you ever lost a pet to an accident? If yes, please explain.*

How do you discipline your pets and for what reason(s)?*

Do you have time to provide adequate attention and training to the dog?*

YesNoMaybe

Do you acknowledge a dog is a lifelong commitment that requires time, patience and regular medical care including vaccinations and monthly heartworm preventative?*

YesNo

Who will have financial responsibility for this dog?*

Do you acknowledge you are prepared for the financial responsibility required to provide food, monthly heartworm preventative, veterinary care and shelter for this pet? Ask us about the most inexpensive ways to purchase wormer and heartworm/flea/tick meds.*

YesNo

Who will have primary responsibility for the dog's daily care?*

Do you agree to provide regular health care by a licensed veterinarian?*

YesNo

Do you have a regular veterinarian? If yes, please provide name and contact information as well as the name the account is in. If you do not have a vet, please provide the name and contact information of the vet you intend to use.*

Do you agree to provide annual vaccinations and monthly heartworm prevention? (It could cost $800-$1500+ for heartworm treatment if the dog is not kept on heartworm preventative year-round.)*

YesNo

If the dog was not able to be spayed or neutered before leaving rescue because of age or other factors, do you agree to have the animal spayed or neutered at one of our preferred veterinarian partners within 30 days? (Valentine K9 Rescue will cover the cost if done at one of our preferred veterinarian partners in Central Arkansas. If the owner elects to pay for the spay/neuter, proof of sterilization is required within 30 days of taking possession of the animal.)*

YesNo

Do you agree to do everything possible to keep the dog safe AND agree to keep a collar with your current contact information on the dog at all times? (Dogs can’t talk! The majority of lost dogs could be reunited with their owners if they only had their owner's contact information on them. We also highly recommend a microchip.)*

YesNo

Do you agree to contact us if you are no longer able to keep or care for this dog?*We will always work with an adopter to rehome one of our rescues should a situation arise.*

YesNo

AGREEMENT

By signing this application, you agree the information provided on this application is true and correct to the best of your knowledge. Furthermore, you agree that any falsification of information will result in an automatic disapproval of your application. If information is found to be falsified after the adoption is complete, you will return the dog to us immediately and voluntarily.

You authorize your vet and landlord, if applicable, to provide reference information to us to support an adoption decision.

Upon adoption approval, you will be ask to sign a contract with terms that coincide with information discussed in this application. You will be obliged to provide the agreed upon medical care, shelter, training and attention to the adopted dog as described in this application. (We do follow up on our dogs that are adopted.)

If for any reason this dog(s) should need to be rehomed, you agree to return the animal to us. (Adoption fees are non-refundable as they are used to pay or reimburse the dog’s medical expenses while under the rescue’s direction including spay/neuter.) If the dog requires being transported back to the rescue, any transport fee will be split between the adopter and Valentine K9 Rescue, not to exceed an expense of $150 for the adopter.

Signature*