Adoption Application

HOW LONG HAS PET #1 LIVED WITH YOU?

ARE THE VACCINATIONS FOR PET #1 TO DATE?
YesNo

HAS PET #1 BEEN SPRAYED OR NEUTERED?
YesNo

PLEASE ENTER ANY ADDITIONAL RELEVANT INFORMATION

VETERINARIAN INFORMATION

Please contact your vet and advise them that 11th Hour Rescue NY will be calling for a "Vet Check" and give your permission to speak to us.

VETERINARIAN NAME *

VETERINARIAN ADDRESS *

VETERINARIAN PHONE (PLEASE INCLUDE AREA CODE *

PERSONAL REFERENCES
Provide two references, only one of which may be a family member

REFERENCE NAME #1 *

REFERENCE ADDRESS #1 *

REFERENCE PHONE #1 *

REFERENCE RELATIONSHIP #1 *

REFERENCE NAME #2 *

REFERENCE ADDRESS #2 *

REFERENCE PHONE #2 *

REFERENCE RELATIONSHIP #2 *

HOUSEHOLD QUESTIONNAIRE

IS ANYONE IN YOUR HOUSEHOLD ALLERGIC TO DOGS *
YesNo

PLEASE EXPLAIN

IF YOU HAVE CHILDREN, PLEASE DESCRIBE ANY EXPERIENCES THEY'VE HAD WITH DOGS

PLEASE CHOOSE WHICH OPTION BEST FITS YOUR LIFESTYLE *
Very activeRegularly exercise outdoorsCoach potato

DO YOU OWN OR RENT YOUR RESIDENCE? *
OwnRent

IF RENTING, PLEASE PROVIDE YOUR LANDLORD'S NAME AND CONTACT INFORMATION

WHAT TYPE OF HOME DO YOU LIVE IN?
HouseTownhouseDuplexCondoApartmentMobile HomeOther

IF OTHER, PLEASE EXPLAIN

DO YOU HAVE A FENCED IN YARD?
YesNo

IF YES, PLEASE DESCRIBE THE TYPE AND HEIGHT OF FENCE

ADOPTION QUESTIONNAIRE

WHAT ARE YOUR REASONS FOR ADOPTING A DOG? SELECT ALL THAT APPLY
Family petChilds petWatchdogCompanionHuntingCompanion for other petOther

IF OTHER, PLEASE EXPLAIN

WHY DO YOU WISH TO ADOPT THIS PARTICULAR DOG?

WHO WILL BE THE PRIMARY CARETAKER? *

THE AVERAGE YEARLY COST FOR A HEALTHY DOG IS BETWEEN $500 TO $700. ARE YOU PREPARED TO BEAR THIS COST? *
YesNo

ON AVERAGE, HOW LONG WILL THE DOG BE LEFT ALONE EACH DAY? *

WHAT ARRANGEMENTS DO YOU EXPECT TO MAKE TO CARE THIS DOG IF YOU ARE AWAY FROM HOME FOR AN EXTENDED PERIOD OF TIME? *

WHERE WILL THE DOG BE KEPT WHEN YOU'RE AT WORK OR OTHERWISE NOT AT HOME FOR BRIEF PERIODS? *

HOW DO YOU PLAN TO EXERCISE THIS DOG? *

WHERE WILL THE DOG SLEEP AT NIGHT? *

SELECT THE KINDS OF PERSONAL SITUATIONS WHERE YOU MIGHT CONSIDER SURRENDERING YOUR DOG? *
AllergiesBehavioral problemsChildren not taking care of the dogDivorceFinancial problemsHousebreaking problemsIt gets too bigMedical problemsMovingNew babyNot getting along with other petsShedding

YesNo

DO YOU UNDERSTAND THAT CHANGING A DOG'S ENVIRONMENT / SCHEDULE MAY CAUSE THE DOG TO HAVE ACCIDENTS? *
YesNo

HOW DO YOU PLAN ON TRAINING THIS DOG? *

ARE THERE ANY HABITS YOU WILL NOT TOLERATE FROM THIS DOG? *