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: ____________________________



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? 



            ___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?


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


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



Home ownership: 

___ 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: 

___ 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:


___ Doghouse

___ Covered area (porch, etc.)

___ Shade trees

___ Other (explain)________________


Care of Animal/ Home Environment:

What problems would make you return an animal? 


___ 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

___ both

___ neither


Under what other possible circumstances would you return the animal: 


___ 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? 


___ 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:



Please list animals you previously owned (other than fish, rodents, or reptiles) and describe what happened to them:

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