MidAtlantic Samoyed Rescue
Pet ownership is a serious commitment that the entire household needs to consider and agree to before the animal is adopted. We want to ensure that each adoptive household is aware of, willing and able to accept, the physical and financial responsibilities of pet ownership. Not everyone who desires to own a pet is ready to properly care for one. This questionnaire will assist both you and us in determining if your household is prepared to assume the role of responsible caretaker for a rescued animal. Thank you for filling it out!
Adopter's Name: _________________________________________
Other Adult(s) at Residence_________________________________
Street Address: ____________________________________________
Telephone numbers: Home: _______________________
Are you 21 years of age or older? _____________ (proof may be requested)
Why are you considering adopting a dog?
Where would the animal be primarily housed?
___About equally inside and outside
Where would the animal stay when you are not home?
___ Loose inside
___ Crated or otherwise confined inside
___ Loose outside
___ Kennel run/fenced area outside
___ Tied/chained outside
___ Other (describe)__________________________
Are you in the military or military reserves? Yes ____ No_____
If yes, what will you do with the dog if your unit is called up or if you are transferred overseas?
Are you in the military or military reserves? Yes ____ No_____
Is there a particular dog of ours that you're interested in?
____ YES - what is the dog's name? ____________________
___ NO, - please note your preferences below so we can let you know when such an animal becomes available:
Type ___ Purebred
___ mixed breed
___ no preference
Sex ___ Male
Age range: _________________
Animals can be expensive to care for (estimated average annual cost is $750 for one dog). Are you willing and able to provide adequate food, shelter and medical care, including yearly checkups and vaccinations, for an adopted animal? ___________
Number of children living in the house:______
Ages of the children_______________
Do they live with you full time?____
Do other children visit? _____________
If yes, what are their ages? ___________________
How often do they visit? _______________________
Others in the home:
Does anyone in your household have allergies to animals? _____
If yes, to what kinds of animals?___________________
your entire household know that you are considering adopting a pet? ________
If no, why not? ___________________________________
__Rural __Suburban __Urban
Do you live in a:
___Single family house
__ Mobile home
___ Do you own you home
____ Do you rent your home
Renters: Please provide a copy of your lease agreement that says dogs are allowed,
along with breed and size requirements. Please list landlord's name and telephone number: ___________________________________________
Describe your yard:
___ kennel run
___ no fence
___ other (describe)_________________________
If fenced or kennel run, describe material used:
___ other (describe)_______________
If fenced, height of fence and approximate size of fenced-in area ________________________________
If fenced, number of gates:_______ Are the gates always securely latched and/or locked?____________
If not fenced, how will dog be allowed out to eliminate:
___Walked on leash
___ Tied up outside
___ Sent out into yard
___ Other ______________
If the animal is outside other than for supervised activities, describe what shelter would be available for it:
___ Covered area (porch, etc.)
___ Shade trees
___ Other (explain)________________
Care of Animal/ Home Environment:
What problems would make you return an animal?
___ jumping up
___ shyness/other fears
___ scratching or climbing on furniture
___ other (explain)_______________________
___ None, I am committed to working with the animal to correct
any of these and most other problems.
To help resolve problems, are you willing to
___ use a crate
___ take an obedience class
Under what other possible circumstances would you return the animal:
___ new baby
___ high cost of animal's care
___ personal illness
___ other (describe)__________________
none that I know of___
Describe your home's activity level:
___ Busy active/noisy;
___ Moderate comings/goings
___ Quiet occasional guests
Do you have a pool? ______ Is it separately fenced? _____
Do you feel that a pet should be spayed/neutered?
___ No. Explain _______________________________
Approximately how many hours each day would the animal be left alone? ________________________
Please list all animals that you presently own (other than fish, rodents, and reptiles):
Type of Animal/Breed Time Owned Age Gender Neutered Vaccinated On Heartworm pills?
Who is responsible for care of the above daily? _____________________ when you are on vacation? ________________________
Name and telephone number of current veterinarian, if any:
3) _________________________________________ 4)_______________________________________
Individuals who adopt a MidAtlantic Samoyed Rescue dog are contacted periodically for an update to help ensure that the animal successfully adjusts to its new life. If you adopt a MidAtlantic Samoyed Rescue dog, do you consent to home visits before and/or after adoption? ___________________________________
What is the best time to call you at home to check on how the adopted animal is adjusting?___________________________________
If at any time an adopter cannot keep the animal, it must be returned to MidAtlantic Samoyed Rescue. If the animal is not spayed or neutered at adoption, the adopter is required to alter the animal and provide a
veterinary certification of altering to MAS Rescue by the date specified in the adoption contract -- animals unaltered by the contractual date may be seized. In addition, each pet adoption is assessed a non-refundable tax-deductible donation, varying by animal to help pay veterinary/other expenses.
By signing below, I acknowledge that I completely read this questionnaire, comprehend it fully, know that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application or the adoption contract can result in the forfeiture of any MidAtlantic Samoyed Rescue dog adopted by me.
Please return this form to:
MidAtlantic Samoyed Rescue, Inc.
PO Box 0526
Mayo MD 21106