Daisy Bean Rescue Adoption Form

Name of dog you are applying to adopt. Write n/a if you are open to us matching you based on best fit.

Your Full Name*

First NameLast Name

Age

E-mail*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number - Home

Format: (000) 000-0000.

Phone Number - Cellular

Format: (000) 000-0000.

Do you live in a:*

Do you:*

OwnRentLive with ParentsOther

If Renting: Please indicate landlord contact information

Household Setting

RuralCity

Describe the Activity Level in your Home

Busy/NoisyModerate Comings/GoingsQuiet with Occasional Guests

Please List all People Living in the Household (Include Name, Relationship, Gender and Age)*

Does Anyone in your Household have Allergies to Animals?

YesNo

Are all members of your Family agreeable to Adopting a Dog?

YesNo

Please List any Pets you have Living or Deceased (Please include Name, Breed, Age, Altered, Sex, UTD Vaccines, Heartworm, Living/Deceased)

All applicants must pass a Veterinarian check. Please provide us with your Veterinarian Name.

First NameLast Name

Vet Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Vet Phone Number

Format: (000) 000-0000.

Personal Reference #1 Name and Number:

Personal Reference #2 Name and Number:

Do you have a preference in the sex of your future dog?

MaleFemaleNo Preference

Are you willing to adopt a dog of any age?

YesNo

If not, what age would you consider?

What size dog are you willing to adopt? (Check all that apply)*

SmallMediumLarge

Please describe the type of dog you are wanting to adopt (Please include breed, coat length, personality traits, energy level, hypoallergenic) We always want to make sure we have the best fit for our dogs' forever homes*

Are you willing and able to take your newly adopted dog to all necessary vet appointments?

YesNo

If No please explain

Are you willing and able to medicate your dog as deemed necessary by a vet, even if it is just a monthly heartworm preventative?

YesNo

We cannot guarantee a dog to be housebroken, are you equipped to train with love and patience?

YesNo

Have you had any experience with with an emotionally or physically neglected or abused dog?

YesNo

If Yes please explain

Are you willing to use a crate for a dog if recommended?

YesNo

Do you have a fenced yard?

YesNoPartial

How many hours in a day would your dog be left alone?*

What are you plans to exercise your adopted dog? Please list any parks nearby or trails, how many walks a day, approximate length, and any additional activities such as agility, swimming, running, etc.*

By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully.

I understand that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application can result in the forfeiture of any Daisy Mae Bean Rescue, Inc. (dba Daisy Bean Rescue and further referred to DBR) animal fostered or adopted by me.

I certify that the above information is correct, and I understand that the information will be verified.

I understand that by submitting this form electronically, I agree to release and covenant to hold harmless DBR and it's members from any claims, damages, costs, or actions incurred because of the care or actions of the foster or adopted dog.

I accept full responsibility for the dog(s) actions at all times, and release DBR from any liabilities or damages that may be incurred because of fostering such dog(s).

I agree to have DBR complete reference call checks and conduct a home visit inspection to be able to approve my foster application.

I agree that if I'm unable to adaquetely provide for the dog(s) anymore that I will return the dog(s) to DBR and try to give DBR a 2 week period to try and find another suitable foster for the dog(s).

Click to edit

Date

Hour MinutesAM/PM Option

Your name*

Co-Applicant name (if applicable)

Full Name

First NameLast Name

Adopt a Daisy Bean Dog