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:

Other

If Renting: Please indicate landlord contact information

Household Setting

Describe your Homes Activity Level

Other

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

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

Other

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

Do you have a preference?

Are you willing to adopt a pet of any age?

If not, what age would you consider & why?

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

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?

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

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

If Yes please explain

Are you willing to use a crate for a dog, if recommended?

Do you have a fenced yard?

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

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Signature