Dog Adoption Application

This questionnaire is designed to help Caring Hearts Dog Rescue and yourself determine if a specific dog is the right one for you and your household. All adopting parties are required to complete this form prior to adoption. Caring Hearts Dog Rescue reserves the right to deny any adoption based on answers to this questionnaire and/or interviews prior to adoptions!

Name of the dog you are interested in:

Your full name:

Your age:

Street Address:

City, State, Zip

Home Phone:

Area CodePhone Number

Work Phone:

Area CodePhone Number

Cell Phone:

Area CodePhone Number

E-mail:

Employer:

Character reference #1 and phone number:

Character reference #2 and phone number:

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

Who will be the pet's primary caregiver?

Do you live in a

Do you own or rent?

If rent, provide name and phone number of landlord:

Does your landlord allow dogs?

Are there any restrictions from your landlord or subdivision?

Do you have a fully fenced yard?

Height and type of fence

Do you have any of the following?

How many adults are in your household?

How many children are in your household?

If children, what are their ages?

Have your children been around animals before?

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

List any pets you own or have owned in the past five years, and their ages

How many of these pets are spayed/neutered?

Where are these animals now?

Have you adopted from an animal welfare group before?

If yes, what group?

Have you ever given up a pet?

If yes, what were the circumstances?

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

Are you aware of crate training?

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

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 new pet sleep at night?

Where will your new dog stay when nobody is home?

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

Are you aware that a new environment is stressful for your pet, and they may exhibit uncharacteristic behavior?

Do you understand that a dog can be an 16 year commitment, and can cost hundreds of dollars per year to care for?

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?

How did you find out about Caring Hearts Dog Rescue

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

Caring Hearts Dog Rescue does not guarantee this animal in any way as to health, performance, behavior, or bloodline. As such, Caring Hearts Dog Rescue is unaware of the medical, genetic, or behavioral history of the animals in our facility. The shelter will advise of any known or observed medical or behavioral issues and will make our best determination as to animal breed mix and age.

When an animal arrives at Caring Hearts Dog Rescue we perform an evaluation, examination and administer initial
vaccinations as necessary to jumpstart the animal’s immune system (if vaccinations are required) and protect the health of other animals in our facility. However, it is possible that an animal could be incubating illness or disease, and vaccines would not protect them.

Rescue animals should be seen by your selected practice Veterinarian. Any additional inoculations and preventative care will be your responsibility. Caring Hearts Dog Rescue will not reimburse any veterinary costs that may be incurred, regardless of the health of the animal rescued. This includes any costs associated with illness of current pets which may have been contracted from your newly rescued pet. We are not responsible for completing surgery or follow up care.

I agree to comply with all City, County, and State codes regarding the care, sheltering, sterilization, and adoption of animals

I acknowledge that all information provided on this form is true and correct. I understand that any misrepresentations may result in my not being approved and/or removal of the adopted dog from my possession. I also certify that I have never been convicted of animal cruelty or neglect.

I agree to allow a representative from Caring Hearts Dog Rescue to contact my vet for a reference.

I agree that if for some reason I am unable to care for the dog, that I will contact Caring Hearts Dog Rescue so that they can take back the dog.

I also agree and understand that spaying and neutering for puppies will be my responsibiity and that Caring Hearts Dog Rescue will help facilitate with their spay and neuter program.

By signing this argreement, you also irrevocably, agree as follows:

1. To indemnify and save and hold harmless Caring Hearts Dog Rescue from and for, any and all liability, claims, suits, proceedings, demands, losses, damages or expense of any name or nature, including administrative orders and proceeding and arbitration, which Caring Hearts Dog Rescue sustains or incurs, including all claims regarding property loss, personal injury or death, resulting in any way, or in any manner connected with your adoption of dog(s) hereinafter referred to as “PET(s)”.

2. You assume full risk of any loss, injury or damages whatsoever occurring caused by or related directly or indirectly to PET(s) upon or after transfer of PET(s) to you.

3. This right of indemnity shall include attorney fees and any and all civil or administrative defense costs as incurred.

4. This Agreement is also a covenant not to sue Caring Hearts Dog Rescue for any cause or matter referred to herein and you agree that the provisions contained herein are intended to be as broad and inclusive as permitted by laws of State of Wisconsin and Texas and if any portion hereof is held invalid,
it is agreed that the balance shall, notwithstanding, continue in full force and legal effect.

Signature

Date:

Dog Adoption Application

Applicant Information

Household Information

Current/Previous Pet Information

New Pet Information