CHESAPEAKE RETRIEVER RESCUE OF WI 
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, and 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. 

The 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.  DO NOT APPLY IF YOU ARE PLANNING TO KEEP THE DOG OUTSIDE EITHER IN A DOG HOUSE OR A KENNEL.
We strive to match the dog to the family.  Filling out the application does not assure that the particular dog you are applying for is the right match for your family or for the dog. Nor does any order of which the application is received have any bearing on the decision.

Are you 21 years of age or older? 				

Date of birth: Month and Year only. _____________________________________

Are you willing to pay an adoption fee?				

Why are you considering adopting a dog?  Hunting_____ Companionship_____ Protection	

Why are you choosing to adopt a Chesapeake?_________________________________
_____________________________________________________________________

Have you ever owned a Chesapeake before?			 If so,how many?			

Where would the animal be primarily housed?							

Where would the dog stay when you are not at home?  Loose inside				
Crated or otherwise confined?				 
Other_____ (Please Explain)										

Is there a particular dog of ours you are interested in? ____________ If yes,what is the dog's name?								

If no, please note your preferences below so we can let you know when such a dog becomes available:  Purebred, mixed breed or no preference?							
Male,female,or either?					 Age range:				 

Animals can be expensive to care for (estimated average cost is $850 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?								
Adopter's Name				_____ Other Adult(s) at Residence  _________________________   Date(s) of Birth/Month and Year _________________

Street Address												
City/State/Zip:												
Telephone: Home					 Work						
EMAIL Address: ____________________________________________________

Number of children living in the house:		 Ages of children:				
Do they live with you full time?									

Do other children visit	 If yes, what are the ages ?						
How often do they visit?										

Does anyone in your house have allergies to animals?____________ If yes, to what kind of animals? 												

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

Household Setting: Rural			 Suburban			 Urban			
Do you live in a House______ Apartment_______ Mobile home________ Town house		
Do you own?		 If you rent, you MUST provide proof of permission to have a dog on the premises.  If renting, landlord's name and telephone number:					

Describe your yard: Fenced			 No Fence		_______

Please note: We do not adopt to homes with underground fencing-no exceptions.

Other (describe)		 If fenced , 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 or locked?		

What problems would make you return a dog? Barking_________ Housebreaking			
Chewing__________ Jumping__________ Shyness/other fears__________ Shedding		 Digging__________ Scratching or Climbing on furniture__________ other (explain)____________________________________________ or none, I am committed to working with the dog to correct any of these and most other problems				

To help resolve problems, are you willing to:  Use a crate			_____

Attend classes:____________________

Under what circumstances would you return the dog: Move___________ New Baby		 Divorce____________ High Cost of Animal's Care____________ Personal Illness		 Other									 None that I know of		

Describe your home's activity level: Busy active/noisy; moderate comings/goings; or quiet occasional guests					

Do you have a pool?  If yes, is it above or in ground?						
If in ground, is it separately fenced?									

Do you feel a pet should be spayed/neutered?				
If no, why not? 											

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

Please list all animals that you presently own  (other than fish and rodents) 
Type of Animal/Breed________________________________________________________ Time Owned____________ Age:_________ Gender____ Neutered_____ Current on vaccines?______Are they on heartworm pills?      Flea and Tick Preventative?__________
Who is responsible of the above daily?						__
Who is responsible when you are on vacation?										
Do you give  permission to contact your veterinarian regarding the care of your present and previous pets?______________  Please contact your veterinarian and give permission for us to access your dog's medical records.

Name and telephone of current or previous veterinarian.																		

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

1)													
3)													
2)													
4)													

Individuals who adopt a rescue dog are contacted periodically for an update to help ensure the dog successfully adjusts to its new life.  What is the best time to call you at home to check on how the adopted animal is adjusting?								

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/and or running  loose, 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 will result in the forfeiture of any Chesapeake Retriever Rescue of WI Inc. dog adopted by me.

Signature								 Date:				
Reviewed by:							

Please return this form either by e-mail, fax or USPS to:

Chesapeake Retriever Rescue of WI. Inc.
1318 S. Kernan Ave.
Appleton,WI 54915
FAX  920-882-0495