Adoption Application

 1.Are you 21 Years of Age?

 2.Date of Birth: Month and Year only 

 3.Are you willing to pay an adoption fee? 

 4.Why are you considering adopting a dog? Hunting   Companionship  Protection

 5.Why are you choosing to adopt  a Chesapeake?

 6.Have you ever owned a Chesapeake before? 

 7.If yes-how many?

8. Where would the animal be primarily housed?

 9.Where would the dog stay when you are not at home? Loose inside,    Crated or otherwise confined,   other-please explain

 10.Is there a particular dog of ours you are interested in?

 11.If yes, what is the dog's name?

 12.If no, please note your preferences so we can let you know when such a dog becomes available.   Purebred, Mixed breed, No preference, Male, Female, Either.  

  13.Age range       young    adult    old  

 14.Animals can be expensive to care for (estimated average 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 dog?

 15.Adopter's name 

 16.Other adults   at residence

 17.Month, Year of birth of other adults

 18.Street address

 19.City, State, Zip

 20.Telephone: Home      Work

 21.Email:

 22.Number of children living in the house: 

22. Ages of children living in the house 

 23.Do they live with you full time?

 24a. Do other children visit?         

24b. If yes, what are their ages?

 25.How often do they visit?

 26a.Does anyone in your house have allergies to animals?       

26b. If yes, to what kind of animals?

 27. Does your entire household know that you are considering adopting a pet?  

 28.Household Setting: Rural , Suburban, Urban

 29.Do you live in a:  House ,Apartment , Mobile home ,Townhouse 

 30a.Do you own?      

30b.  If you rent, you MUST provide proof of permission to have a dog on the premises.  If renting, landlord's name and telephone number.

 31.Describe your yard:      Fenced   or No Fence

 32.Other (describe)

 33.If fenced , describe material used:   Chain Link, Wood, other (describe)

 34.If fenced, height of fence and approximate size of fenced in area

 35.If fenced, number of gates 

 36.Are the gates always securely latched or locked? 

 37.If the animal is outside in a fenced yard other than for supervised activities, describe what shelter would be available for it  :  Covered area (porch, etc)     

 38a.Shade trees            38b.Other (explain)

 39.What problems would make you return a dog? Barking, Housebreaking, Chewing, Jumping, Shyness/other fears , Shedding-Digging-Scratching, Climbing on furniture or other (explain)      

39b.none, I am committed to working with the dog to correct any of these and most other problems-yes or no

 40. To help resolve problems, are you willing to Use a crate      or 40b) Take an obedience class  

 41.Under what circumstances would you return the dog: Move, New Baby, Divorce, High Cost of Animal's Care, Personal Illness , Other or None that I know of    

 42.Describe your home's activity level: Busy active/noisy, moderate comings/goings, quiet occasional guests       

 43a.Do you have a pool?            44b.If yes, is it above or in ground?   

 45. If in ground, is it separately fenced  

 46.Do you feel a pet should be spayed/neutered?    

 47.If no, why not?

 48.Approximately how many hours a day would the dog be left alone?

 49.Please list all animals that you presently own  (other than fish and rodents)

 50a.Type of Animal/Breed 50b.Time Owned 50c.Age:  50d.Gender   50e.Neutered  50f. Current on vaccines?          

 51.Are they on heartworm pills?     

 52.Who is responsible of the above daily? 

53.When you are on vacation?

 54.Do you give  permission to contact your veterinarian regarding the care of your present and previous pets?      

 55.Name and telephone of current or previous veterinarian.

 56.Please list animals you previously owned and describe what happened to them:

 57.Individuals who adopt a rescue dog are contacted periodically for an update to help ensure the dog successfully adjusts to its new life.   If you adopt a dog from Chesapeake Retriever Rescue of WI Inc., do you consent to home visits before and after adoption?   

 58.What is the best time to call you at home to check on how the adopted animal is adjusting?

 59.Additional information you wish to provide:

If at any time an adopter cannot keep the dog, it must be returned to Chesapeake Retriever Rescue of WI Inc.  If the animal is not spayed or neutered at adoption, due to age, the adopter is required to alter the animal and provide a veterinary certification of altering to Chesapeake Retriever Rescue of WI Inc. 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 non-tax deductible fee, varying by animal to help pay veterinary expenses. If a dog adopted from Chesapeake Retriever Rescue of WI is found to be living outside, the dog will be seized and returned to rescue.

 

By signing below, I acknowledge that I completely read this application, 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 Chesapeake Retriever Rescue of WI Inc. dog adopted by me.

 60. Signature      Date:                                      

Please  put your initials ( considered electronic signature) in the signature line

Reviewed by:

 

Chesapeake Retriever Rescue of WI. Inc.

1318 S. Kernan Ave.

Appleton, WI 54915

FAX  920-882-0495

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Copyright © 2008 Chesapeake Rescue of Wisconsin Inc.
Revised: 03/07/08.