Yorkie & Small Dog Rescue Adoption Application |
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| First Name: |
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| Last Name: |
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| Your Age: |
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| E-mail Address: |
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| Home Phone: |
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| Cell Phone: |
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| Business Phone: |
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| Your Occupation: |
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| Spouse Name: |
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| Spouse Occupation: |
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| Spouse Business Phone: |
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Dwelling Information |
| Street Address: |
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| City: |
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| State: |
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| Sub-Division Name: |
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| Dwelling Type: |
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| Own or Rent? |
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| Landlord's Name (if renting): |
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| Landlord's Phone Number: |
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| Driver's License Number: |
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General Questions |
| Number of Children and ages in your Household: |
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| How did you find YSDR? |
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| Name of Dog you are interested in adopting? |
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| Prefer Male or Female Pet? |
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| Willing to Adopt pet of any age? |
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| Have you owned a dog before? |
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| Where did you get your past pet? |
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We do not guarantee a dog to be housebroken? Are you equipped to train with love and patience? |
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| How do you plan on house training your pet? |
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| Have you had any experience with an emotionally or physically neglected or abused dog? |
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| Please list names of past pets and causes of death: |
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| Please list the names of your current pets (very important!) |
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| What brand of heartworm prevention are your dogs on? |
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| Are your pets neutered? |
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| If no, please explain why: |
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| Where do your current animals stay? |
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| If outside or other, please explain: |
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| Are all members of your family agreeable to adopting a dog? |
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| Anyone in your household allergic to animals? |
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Who will have primary responsibility for the care of the dog? |
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| How many hours a day (average workday) would your dog be left alone? |
Hrs |
| Do you have a fenced yard or fenced area? |
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| Please describe your fenced area |
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| Do you have a pool? |
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| If yes, how do you plan on protecting your dog from drowning? |
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| Do you have a dog door? |
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| During the Day? |
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| At Night? |
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| While you are not at home? |
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If you are ever away for a few days, who would take care of your dog? |
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| Please give name, address, and phone number of your dog groomer: |
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| Please list your present AND PAST Veterinarian's name, address, and phone numbers: |
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| Please provide 3 personal references with names, addresses, phone numbers, and how related: |
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More Important Questions |
| Are you willing to have a member of rescue and adoption organization visit with you in your home, by appointment prior to and after any adoption? |
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| If no transportation can be found, will you be willing to travel to collect a dog? |
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We require an adoption fee to defray veterinary and other expenses. Are you willing to do so? |
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By Signing this document, I accept it as a binding contract and understand and agree to the following- |
- Any dog adopted from YSDR is to be an indoor dog and treated as a member of your family.
- Any dog adopted from YSDR shall be afforded all necessary vaccinations, licenses, heartworm and flea prevention, plus any medical treatment that may become necessary.
- If for any reason, you can no longer care for your adopted dog, it must be returned to YSDR.
- YSDR retains the right to remove a dog adopted from us that has been deemed abused, neglected, or found to be in a situation that may not be in the best interest of the dog.
- I hereby give permission for my Veterinarian to release information to YSDR on any pets that I have owned, live or deceased.
- YSDR reserves the right to refuse a dog to any applicant.
- Any misrepresentation of fact may result in my not being approved to adopt a dog from YSDR.
- All information I have given on this form is true and correct.
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| Additional Comments |
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| Typed Full Name (Signature) |
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| Today's Date: |
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| Type the code (black letters only) in the box provided to prove you are human (anti-spam) |
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By pressing submit, I hereby agree to the above terms and conditions given by Yorkie and Small Dog Rescue. I also acknowledge that filling out the application does NOT guarantee acceptance. |
