Today's Date. *
Input mm/dd/yyyy
Name of the pet you want to adopt. *
Enter the pet's name that you want to adopt. If you want more than 1 pet, enter the first name, then "/", then second name.
Your first name. *
Enter your first name.
Your last name. *
Enter your last name.
Address. *
Your street or country address.
City. *
Your city.
State. *
Your state.
Your zip code. *
Your zip code.
Your home phone number.
Your home phone number.
Your cell phone number.
Your cell phone number.
Your email address. *
Enter your email address.
NAMES and AGES of all people living in your household, including yourself. If this information is not provided, your application will not be considered. *
NAMES and AGES of all people living in your household, including yourself. If this information is not provided, your application will not be considered.
If any children under 18, have they been previously exposed to dogs? *
Have any children under 18 in this household been previously exposed to dogs? Check yes or no. (Please keep in mind that a young puppy may jump on, lick, chew, or even nip a small child until they learn this is not acceptable behavior.)
No Yes
How soon will you be ready to adopt? *
Give an estimate on how soon you will be ready to bring your new dog home.
Why do you want to adopt a new dog/puppy? *
Give a short explanation on why you have decided to adopt a dog or puppy.
Do you own or rent your home? *
Choose Own or Rent.
Own Rent
If you rent, provide the name and phone number of your landlord.
Enter your landlord's name and phone number.
Is your home a single family home, apartment, duplex or trailer?
Choose from the choices provided.
Single family home Apartment Duplex Trailer
Are you looking for a dog which will live mainly as an indoor dog, or as an outside dog?
Choose one of the choices.
Indoor dog Outside dog
Do you have a fenced yard? If yes, describe your fence *
Enter yes or no and the type of fence you have, if you have one, such as chain-link or wood, etc.
If no fence, how will you exercise and potty the dog? *
Describe how you will exercise or take out your dog to potty.
Where will your dog sleep at night? *
Where your dog will sleep at night.
How much time on most days will this dog spend alone? *
Approximate time that dog will be alone each day.
Where will your dog stay when left alone? *
Where will your dog be when staying along?
In an average week, how many hours will the dog be left outside while no one is home? *
Enter approximate hours.
Do you currently have any other pets? If so, list breed and ages. *
List each current pet with breed and age separated by commas. (Such as: Rufus, German Shepherd mix, 8 and Sadie, cat, 4)
If you have other pets, are they all spayed or neutered and current on vaccines? *
Choose yes or no.
No Yes
If they are not spayed or neutered and current on vaccines, why aren’t they?
If not, which one(s) are not, and why?
Do you give heartworm prevention to your dogs? *
No Yes
If you do not give heartworm prevention, why?
Describe your reason for not giving heartworm prevention to your dog.
Your veterinarian's name and phone number.
Enter your veterinarian's name and phone number (including area code).
List any previous pets that you have had within the past 5 years and why they are no longer with you.
List any pets you have had in the last 5 years that are no longer with you and why.
Do you have the time, patience, love and physical ability to care for this dog? *
No Yes
Are you prepared for chewing, digging, scratching, house training, etc? *
No Yes
If approved, are you willing to work with this dog, and your existing pets (if applicable), as this dog gets acclimated to its new home? *
No Yes
What reason(s) would cause you to give up a pet? *
Have you ever surrendered a pet to an animal shelter, or rehomed a previous pet? If yes, why? *
Is there anything else you’d like to share with us regarding the type of home you can provide for this dog?
Personal reference 1 name. Please do not list Family members *
Please do not list Family members
Personal reference 1 email address. *
Personal reference 1 relationship to you. *
Personal reference 2 name. Please do not list Family members. *
Please do not list Family members
Personal reference 2 email address. *
Personal reference 2 relationship to you. *
Please ask your references to email rescuejeanann@aol.com to provide a reference for you. Both references need to be received before your application will be considered. Thank you for choosing to rescue! *
Do you understand?
No Yes