Adoption Form - LittleRhodyRescue.org

Desired Pet

Name

First

Last

Email

Phone

Address

Occupation

How did you here about LRR

Associate/Friend
Web Site
Another Animal Rescue Association

Do you have a Veterinarian?

Yes
No

Vet Clinic Name

Vet Phone Number

Personal Reference #1

Personal Reference #1 -Phone #

Personal Reference #2

Personal Reference #2 -Phone #

Own a Home or Rent?

Home
Rent

Years at current address?

Selected Value: 0

If rent, has Landlord provided written approval to have a dog?

Yes
No
N/A

Landlord Name

Landlord Number

Do you have any pet restrictions?

Yes
No
Unsure

Do you have a fenced in yard? Please Describe below

Allergies to dogs in family?

Yes
No
Unsure

Does everyone in the house want to adopt?

Yes
No

Do all household members agree to socialize the dog?

Yes
No

Any Children under the age of 10 in the household?

Yes
No

Any regular contact with children under 10?

Yes
No

Please describe the regular contact with children under 10 scenario(s) below:

Please list all members of your household including ages, starting with you, below:

Please list all dogs in your household, include: Name, Gender, Breed, Age, Alerted, and up to date on all vaccinations and heartworm?

How many dogs have you owned in the last 5 years?

Selected Value: 0

If you no longer have them, what happened to them?

Please list all cats in your household, include: Name, Gender, Breed, Age, Alerted, and up to date on all vaccinations?

Please list all other pets living in your home (type, name and age):

If there are no other animals currently living in your home, will your rescue dog have regular contact/socialization with others?

Yes
No

Have you ever sold or surrendered a pet?

Yes
No

Please explain:

Your preferences for a dog's age?

Your preferences for a dog's size?

Your preferences for a dog's gender?

Female
Male
It Doesn’t Matter to Me

Your preferences for a dog's coat?

Short Hair
Long Hair
It Doesn’t Matter to Me

Your preferences for a dog's coat color?

Your preferences for a dog's energy level?

How Active are you and your family?

Not at all
Not very
Moderately
Very

How do you plan to exercise the dog?

Are you familiar with the use of a dog crate to train and/or confine the dog during your absence or at night?

Yes
No

Are you planning to use a crate?

Yes
No

Training a dog is mandatory. Do you vow to take your new pal to a trainer?

Yes
No

How many hours per day will your dog(s) be home without humans on a regular basis?

Selected Value: 0

Where will the dog(s) be when you are not home?

Where will the dog(s) be when you are home?

Where will the dog(s) be at night?

What will you do with your dog(s) if you need to be away from home overnight?

If you move, what will you do with your dog(s) and other pets?

Would you agree to return the dog to the rescue if you were unable to keep him/her?

Yes
No

Have you ever been convicted of animal abuse? Domestic Abuse? Physical assault?

Yes
No

It is IMPERATIVE that you notify Little Rhody Rescue & Quarantine Inc. at the onset of any type of illness or health problem within thirty (30) days following an adoption. Do you promise to tend to this if there should be an illness or issue?

Yes
No

What would you do if one of your pets requires significant medical attention?

Are you aware that costs of maintaining a dog can average $500 or more a year (food, annual check-ups & shots, heart worm & flea/tick prevention, grooming, etc.)?

Yes
No

Would you consider a special needs or handicapped dog that may require medication for a permanent (but controllable) condition?

Yes
No
Maybe

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