Jack Russell Rescue CA Adoption Application
Saving little white dogs with big hearts!
Name of Terrier you would like to adopt?
If Applicable
Personal Information
Full Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Alternative Number
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
United States
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Liberia
Libya
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Lithuania
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Macedonia
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Malaysia
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Mali
Malta
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Martinique
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Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
If you are not inquiring about a particular terrier, please give sex and age of terrier you would be interested in adopting.
If approved when could you take possession of the Terrier?
How far are you willing to drive to pick up a dog?
Why do you want to adopt a terrier, eg companion for yourself /other pet / for children / watchdog?
Have you ever taken an animal to a shelter or released it to another party?
Would you be willing to allow a volunteer to make a home visit at a mutually agreed time? Please note: A property inspection is required prior to adoption, to ensure the safety of your Jack Russell Terrier.
Do you own your home? If you are renting, please provide us with your landlord's Name and Phone number:
Please provide an Emergency Contact
*
First Name
Last Name
Emergency Phone Number
*
-
Area Code
Phone Number
E-mail
Address - if different to above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Do you currently have a vet? If so, please provide us their name and phone number so we can contact them for a reference, together with one personal referee. If you do not have a vet please provide two personal references. We reserve the right to contact these referees should the application proceed.
Vet Name
Vet Phone Number
-
Area Code
Phone Number
Vet E-mail
Reference 1 Full Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-mail
Reference 2 Full Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-mail
Is there anything else you would like to tell us about you, your family or your interest in adopting a Jack Russell terrier? The more information you provide, the better we will be able to determine suitability of a particular dog.
Your Home
Number of adults living at premises?
Ages?
Will your new dog have regular contact with children 5 years or under (own children, grandchildren, visiting children) or elderly people? Please describe.
Are you planning on having children in the next 5 years?
Do you currently have any pets? Please give breed, size, sex and age.
If you have a dog(s) are they: Altered?
Microchipped?
Vaccinated
Vet Insurance?
Where do your current pets sleep? Where will the new dog sleep? Please be specific eg kennel, garage, laundry. If inside, which room?
Which areas of the house will your Jack Russell Terrier have access to, eg backyard and laundry/ kitchen/non-carpeted/other areas? Do you have a doggie door? Are there any areas which are off limits?
Is your yard securely fenced? Describe type of fencing (wooden, block, wire etc) and height at the lowest point. If you have a swimming pool is it separately fenced?
If no-one is at home, where will your new dog stay? Inside or Outside? If the dog is outside, what type of shelter will the dog have?
How many hours will the new dog be without human company for each day?
How many dogs are you allowed by your local municipality?
What activities do you plan with this dog? (Pet, Guard, Hunting, Obedience, Terrier Trials, Other (Describe).
How will your Jack Russell Terrier be introduced to your existing pets? What specific steps will you take to integrate them?
Please tell us what breeds of dogs have you previously owned and have you ever owned a Jack Russell terrier?
Please tell us what research have you undertaken to find out more about the Jack Russell terrier breed?
Please tell us how often will you have time to walk your new dog? How long for? On lead or off lead?
There is usually an adjustment period, until a new dog settles in, how do you plan to make your new dog feel at ease and how will you cope with the possible complications that may arise?
Under what circumstance would you give up your new dog, e.g. family illness, barking, digging, shedding, allergic to dog, destructive chewing, biting, growling, moving house, reactivity on lead, lack of house training, cost of food/care?
JRRCA Adoption Terms & Conditions
I agree that this Jack Russell Terrier is being adopted for myself and will not be sold, adopted, or given to another party.
I agree that this dog will not be allowed off my premises unsupervised. When taking this dog out or travelling by car, I shall remain vigilant and he/she will be secured by a harness and/or collar and lead and will wear an ID tag.
I agree that this dog will be a companion animal and will live as part of my family, he/she will not be used as a guard dog.
I agree to care for this dog in a humane manner. This includes providing adequate, food, water, shelter, attention and veterinary care.
I understand and agree, that it is a Jack Russell Rescue Ca requirement that this dog is desexed prior to adoption.
I agree that if I have any training issues or difficulties with this dog, I will contact Jack Russell Rescue Ca for advice.
I agree that if this dog is rehomed as an only pet, I will not attempt to bring other animals into the home.
If this dog is rehomed with another pet, I agree to carefully supervise them when they are together and will not leave them alone together until I am sure that there will be no conflict.
I agree to keep Jack Russell Rescue Ca updated with my current contact details.
I agree that if at any point I am unable to keep this dog, I will return him/her to Jack Russell Rescue Ca, without requesting a fee.
If a terrier is matched to your application and placed in your home, you must agree to keep the terrier for at least 3 weeks (to allow time for the terrier and you to acclimate with each other).
I understand and agree, that although every dog adopted has been tested for temperament & behaviour, I agree to adopt the named dog at my own risk and indemnify and release Jack Russell Rescue Ca, its director and volunteers, of any and all liability arising from damages to person(s) or property caused by the dog.
I agree that all statements on this form are true. If it is found that any statements are untrue, the adopted dog may be confiscated.
Agreement with Terms and Conditions
I have read and fully understand the Terms and Conditions of this agreement and agree that it is not arbitrary and that provisions herein, are common in pet adoption agreements.
By submitting this form, you are agreeing to the above Terms & Conditions.
Signature
Date
-
Month
-
Day
Year
Date Picker Icon
Submit
JRRCA Representative
First Name
Last Name
Adoption Date
Adoption Fee
Name of Terrier
Sex
Age or Birth Date
Color/Coat
Distinctive Markings
Microchip Number
Should be Empty: