Adoption Application

Which 11th Hour Rescue NY Dog to you wish to adopt?

—Please choose an option—Foreman

Your name *

Your email *

Street *

PET #2

PET NAME #2

TYPE / BREED OF PET #2

HOW LONG HAS PET #2 LIVED WITH YOU?

ARE THE VACCINATIONS UP TO DATE FOR PET #2?
YesNo

HAS PET #2 BEEN SPRAYED OR NEUTERED?
YesNo

PLEASE ENTER ANY ADDITIONAL RELEVANT INFORMATION FOR PET #2

PET #3

PET NAME #3

TYPE / BREED OF PET #3

HOW LONG HAS PET #3 LIVED WITH YOU?

ARE THE VACCINATIONS UP TO DATE FOR PET #3?
YesNo

HAS PET #3 BEEN SPRAYED OR NEUTERED?
YesNo

INFORMATION ABOUT YOUR PAST PETS

PAST PET #1 NAME

TYPE / BREED OF PAST PET #1

WERE THE VACCINATIONS UP TO DATE FOR PAST PET #1?
YesNo

WAS PAST PET #1 SPRAYED OR NEUTERED?
YesNo

IS PAST PET #1 DECEASED?
YesNo

PLEASE ENTER ANY ADDITIONAL RELEVANT INFORMATION FOR PAST PET #1

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

ARE YOU WILLING TO TAKE THE TIME TO HOUSEBREAK THIS DOG? *
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? *

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