Adoption Application

How did you hear about us?

Facebook or other Social MediaA friendFrom an EventOther

Full Name*

First NameLast Name

Age*

*Must be 18+

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number - Cellular*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Do you live in a:*

Do you:*

OwnRentLive with ParentsOther

If Renting: Does your landlord and/or property Allow Pets?

If Renting: Please provide landlord contact information.

Are there any Breed Restrictions in your living community or landlord requirements?

If yes, Please indicate breed restrictions.

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 in your home currently with age.*

Name of Pet, Type of Pet, Breed, Age

Please provide pictures of your Pets. (Not Mandetory)

Browse Files

Are All Pets in your Home Altered?*

To support the Rescue Dog Community in all of our efforts, all Dogs in the Home must be Altered unless the dog is not of age or has a medical condition not allowing the dog to be altered. If no, this will be reviewed by the Rescue Director for approval.

Would you be willing to have a Team Member from Empowering Pawz call your veterinarian for a reference check? (Please authorize vet to speak with us)*

YesNo

Veterinarian Name*

Clinic Name. Please put N/A If none.

Phone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Are you willing to provide your pet(s) health/vaccine records to a Team Member of Empowering Pawz?*

YesNo

What timeframe are you considering Adopting? Please note, if you are looking to Adopt 3 months past the application date, you may be required to fill out a new application.*

I'm Ready NowIn the next MonthIn the next 2-3 Months

Is there a dog that you are currently interested in?

If yes, please list dog name(s) here

If there is not a dog that you are currently interested in, please fill out the below questions.

Do you have a preference in the sex of dog?

MaleFemaleNo Preference

What age range are you looking for in a dog? (Check all that apply)

Puppy (8wks to 1 year)Young (1-3 years)Adult (3-5 years)Senior (5+ years)

What size dog (full-grown) are you looking to adopt? (Check all that apply)

SmallMediumLarge

Please describe the type of dog you are looking to adopt (Please include breed, coat length, personality traits, energy level, hypoallergenic)

Are you willing to provide veterinary care and up-to-date vaccines & prevention treatment for your new dog?*

YesNo

If No, please explain

Are you willing to provide documentation of alter of your new dog within 3 months of adoption? (if not already done so)*

YesNoN/A

Have you ever re-homed or surrendered a pet before*

YesNo

Under what circumstances would you consider rehoming/ surrendering your new dog?*

If you would not consider rehoming/surrendering please put N/A

How much time are you willing to give your dog to adjust in his/her new surroundings?*

We cannot guarantee a dog's temperament or behavior. Please describe how you would handle the dog if he/she is showing signs of fear/resource aggression or guarding?*

Are you willing to utilize a professional trainer to correct any issues with your new dog?*

YesNo

Do you have a fenced yard?*

YesNoPartial

If fenced, please give details on height, material, # of gates, are gates locked or lockable?*

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

Where would your new dog spend most of his/her time?*

What would you do with your new dog if you needed to leave town?*

Example: take the dog with you, dog boarding...

Refrences: Please list 2 references (only 1 family member, please)

Reference 1 Name*

Please type full name

Reference 1 Contact*

Provide phone # or e-mail address

Reference 2 Name*

Please type full name

Reference 2 Contact*

Provide phone # or e-mail address

Please use this space to let us know anything else that you would like to add about yourself!

*If you are a vetran, active military, police, firefighter, or teacher, you may be entitled to a lower adoption fee through our Grant Funds, please note in the box above if you would like to apply for these funds as part of your adoption application*

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 Empowering Pawz animal 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 Empowering Pawz and it's members from any claims, damages, costs, or actions incurred because of the care or actions of the adopted dog.

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

I agree to provide continued vetrinary care to the dog adopted through his or her life and provide proof of alter (spay/neuiter) if not already done so through the rescue within 3 months of the adoption date.

I understand that after the 2 day trial period, the adopted dog is under the full responsibility of myself and any listed caregivers. If after the 2 day trail, I decide that the dog is no longer a fit for my home I will contact the director of Empowering Pawz and will need to keep the dog until an approved foster is found.

I agree to not surrender the adopted dog to a shelter or rehome the dog. All surrednered dogs adopted through Empowering Pawz must be returned to the rescue group Director.

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

THANK YOU FOR YOUR TIME IN FILLING OUT THIS APPLICATION.

PLEASE NOTE: Our volunteers may not get back with you for up to 5 days. If you do not get a response on your application within 5 days, please send an e-mail to empoweringpawz@gmail.com.

YOU ARE MAKING A MAJOR COMMITMENT WHEN YOU ADOPT ANY PET. PLEASE REMEMBER THAT DOGS CAN LIVE FOR OVER 20 OR MORE YEARS. THOUSANDS OF DOGS ARE KILLED AT ANIMAL SHELTERS EACH YEAR BECAUSE THEIR OWNERS DID NOT PLAN FOR THE FUTURE. DOGS CAN GET SICK AND REQUIRE EXPENSIVE MEDICAL TREATMENT DURING THE COURSE OF THEIR LIFE. DOGS NEED AFFECTION, ATTENTION AND UNDERSTANDING. YOU MAY HAVE TO ADJUST YOUR LIFESTYLE TO ACCOMMODATE A NEW PET. IF YOU ARE READY TO MAKE THIS COMMITMENT, PLEASE TYPE YOUR NAME BELOW:

Adoption Fees start at $295, and could be more depeneding on the medical attention needed for the dog you are applying for. All dogs adopted through Empowering Pawz have had the minimum age appropriate vaccines which would include:

5-in-1 Vaccine(DA2P+Parvovirus) *min. 2nd round
Deworming
Microchip
Rabies (if age appropriate)
Bordetella (if requested)
HW Test (if age appropraite)
Alter (spay/neutered) if age appropriate 6mo or older +$150

If your adopted dog is not already altered (spayed/neutered), you will pay an additional $150 adoption fee and will receive a spay/neuter voucher. Once proof of alter is done, you will receive a $150 refund within 60-days of the alter from Empowering Pawz. You may choose to alter your dog through our low-cost clinics or through your primary vet. The voucher is only good for $150 of the total expenses. Please reference the "Alter (Spay/Neuter)" form for details.

Reimbursement schedule if the dog is returned to Empowering Pawz.

100% reimbursement if the dog is returned within the 2-day trial period
50% reimbursement if the dog is returned within 14 days of adoption
No reimbursement given if the dog is returned after 14 days of adoption.

Your name*

Co-Applicant name (if applicable)

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Signature

Dog Adoption Application