Form

Name of Terrier you would like to adopt

Full Name *

First Name Middle Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *

Home Phone Number *

- Area Code Phone Number

Mobile Phone Number *

- Area Code Phone Number

If you are not inquiring about a particular Terrier, please give age & sex of Terrier you would be interested in adopting

If approved, when could you take possession of the Terrier ?

How far are you willing to travel to meet a Terrier(s)?

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 Mobile Number *

- Area Code Phone Number

Phone Number

- Area Code Phone Number

E-mail

Address - if different than above

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	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 reference. If you do not have a vet please provide two personal references. We reserve the right to contact these references should the application proceed.

Vet Name

Vet Phone Number

- Area Code Phone Number

Vet E-mail

Reference 1 Full Name

First Name Last Name

Reference 1 Phone Number

- Area Code Phone Number

Reference 1 E-mail

Reference 2 Full Name

First Name Last Name

Reference 2 Phone Number

- Area Code Phone Number

Reference 2 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

Number of adults and their ages living at premises?

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 I 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 housetraining, cost of food/care?

Today's Date *

- Month - Day Year

RUSSELL RESCUE CA

ADOPTION APPLICATION

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