Reflextion Ranch Adoption Questionnaire

Full Name*

First NameLast Name

Age *

Must be 21 or older to adopt. Please contact the rescue directly for more information or questions regarding the age requirement.

Birthdate*

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number - Home

Area CodePhone Number

Phone Number - Cell*

Area CodePhone Number

Phone Number - Work

Area CodePhone Number

What type of Home do you live in:*

Do you:*

OwnRentLive with Parent(s)Other

If Renting: Please indicate landlord contact information

Household Setting*

RuralSuburbanUrban

Describe your Homes Activity Level*

Busy/NoisyModerateCalm/QuietOther

People Living in the Household (Name, Relationship and Age)*

Are all members of your household agreeable to adopting a pet?*

YesNoOther

List any Pets you have. Please include: Name, Breed, Age, Sex, Altered, UTD Vaccines, Monthly Preventatives & personality.*

Do you have a preference?*

MaleFemaleNo Preference

Are you willing to adopt a pet of any age?*

YesNo

If not, what age would you consider & why?

What size pet are you looking for? (Check all that apply)*

SmallMediumLargeX-Large

Please describe the type of pet you are looking to, or would like to, adopt Please include: breed, coat length, personality traits, energy level, age, social needs. *

Are you willing and able to medicate your pet as needed?*

YesNo

We cannot guarantee a pet to be housebroken. Are you equipped to & comfortable with house training ?*

YesNo

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

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 do you plan to and/or currently, exercise your pet(s)?*

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

Please use this space to tell us anything else you think is important or any questions you may have.

Vet Reference: Full Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Personal Reference Full Name:*

First NameLast Name

Relation to applicant(s):

E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

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 agreed upon requirements of this application can result in the forfeiture of any REFLEXTION RANCH pet(s).

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 REFLEXTION RANCH and it's members from any claims, damages, costs, or actions incurred because of the care or actions of the adopter or members of said houshold.

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

I agree to have REFLEXTION RANCH complete reference checks and *possibly* conduct a home visit virtually or in person, to be able to approve my adoption application.

I agree that if I'm unable to keep or humanely care for the animal(s) anymore that I will return the dog(s) to REFLEXTION RANCH and *try* to give REFLEXTION RANCH a 2 week period to try and find another suitable home or facility for the dog(s).

Date*

MonthDayYear

Your name*

E-mail*

Please upload a copy of your current license, Passport or state issued ID*

Browse Files

Signature*