MidAtlantic Samoyed Rescue
Adoption Application
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: ____________________________________________
City/State/Zip:
__________________________________________
Telephone numbers: Home: _______________________
Work: ___________________________
Cell: ____________________________
Email____________________________________________
Are
you 21 years of age or older? _____________ (proof may be requested)
Why are you considering adopting a dog?
___ Hunting
___ Companionship
___ Breeding
___ Protection
Where would the animal be primarily housed?
___Inside
___Outside
___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
If yes, what will you do with the dog if your unit is called up or if you are transferred overseas?
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
___ female
___ either
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?
___________
------------------------------------------------------------------------
Family Considerations
Children:
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?___________________
Does
your entire household know that you are considering adopting a pet? ________
If no, why not? ___________________________________
Residential
Setting:
Household setting:
__Rural
__Suburban __Urban
Do you live in a:
___Single family house
__ Apartment
__ Mobile home
__
Townhouse
___Other________________________________
Home ownership:
___ Do you own you home
____ Do you rent your home
Renters: If you rent, you MUST provide proof of permission to have a dog on the
premises. Please list landlord's name and telephone number:
___________________________________________
Outdoors:
Describe your yard:
___ fenced
___ kennel run
___ no fence
___ other
(describe)_________________________
If fenced or kennel run, describe material used:
___ chain-link
___ wood
___
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:
___Shed
___ Doghouse
___ Covered area (porch, etc.)
___ Shade trees
___
Other (explain)________________
Care
of Animal/ Home Environment:
What problems would make you return an animal?
___barking
___ housebreaking
___ chewing
___ jumping up
___ shyness/other fears
___ shedding
___ digging
___ 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
___ neither
Under what other possible circumstances would you return the animal:
___Move
___ new baby
___ divorce
___ 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?
___Yes
___
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:
_____________________________________________________________________________________
1) _________________________________________
2) ______________________________________
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.
Signature:
______________________________ Date:
________________
Reviewed
By: __________________
Please
return this form to:
MidAtlantic Samoyed Rescue,
Inc.
PO Box 0526
Mayo MD 21106