Adoption Application

Instructions: 

Fill out the application as completely as possible. The more information we have to get to know you, the better chance we have of finding the right match for you. You may add additional comments at the end if you have more information that you think we should know when we consider your application.  Applicant must be at least 18 years old.

This form must be completed in one session. You can not save an incomplete form and come back to it later.  If you fail to complete the form and press “Submit”, your information will be lost.

Upon successful submission of your form, you will see a confirmation message on your screen, and our system will send an email acknowledgement to you confirming your successful submission. If you don’t receive this email within 3 to 5 minutes, please check your spam or junk folder. If you don’t get the email acknowledgement, it is safe to assume that we didn’t get your application.

If you would like to download a PDF copy of this application and mail it back to us, you can download the PDF version by clicking HERE.

    Section I: About You Applicant Name:
    Street Address:
    City, State Zip:

    Home Phone:
    Work Phone:
    Cell Phone:

    E-mail Address:
    Birth Year:

    Employer:
    Position:
    Work Schedule: Full TimePart TimeRetiredOther
    How long employed there:

    Are or were you in the military? Yes - ActiveYes - ReserveYes - Discharged or RetiredNo
    References (By completing this section, you give us permission to contact these people on your behalf)

    1. Local non-relative, not living with you, who knows you well and perhaps has known your animals.
    Name:
    Full Mailing Address:
    Phone:

    2. Relative (not living with you):
    Name:
    Full Mailing Address:
    Phone:

    3. Veterinarian:
    Vet Phone:
    Section II: About Your Home What are your living arrangements? Please check all that apply: OwnHouseTownhouseRentApartmentMobile HomeLive with parentsDuplexOther
    How long have you lived at this residence?

    If renting, please provide your landlord’s contact information below. You give Rescued Rollers permission to contact your landlord.
    Landlord Name:
    Address:
    Phone Number:
    Are there any lease restrictions that prevent you from having a dog, or certain breeds, or a size limit on a dog? YesNo
    If yes, please explain:

    Do you have permission from the property owner to have a dog? (Proof of ownership or lease with pet clause may be requested.) YesNo
    Do you have a yard, securely and physically fenced so that a small animal could not escape? YesNo
    Describe the fence material and height:
    Does a door from your house open directly into the fenced yard? YesNo
    How large is your fenced area?
    If you don’t have a fence, how do you plan to contain your pet when it is outside?

    Please tell us about the ages and relationship (to you) of all the people who live in your home:

    Do any children visit on a regular basis (for example, grandchildren)? YesNo
    If yes, what are their age ranges?
    Section III: About Senior, Special Needs, or Other Pets and You
    Have you ever owned a senior or special needs pet? If so, please tell us about that experience:


    Where will this pet be kept while it is alone during the day?
    Where will this pet be kept while it is alone at night?
    Is anyone home during the day? YesNo
    Approximately how many hours will this pet be alone each day?
    Who will be responsible for the primary care of this pet (feeding, exercising, etc.)?

    How frequently do you travel?
    Who will care for this pet if you are away on overnight absences?

    How will you pay for unforeseen emergency care?
    How will this pet be allowed to relieve itself daily? I will let it out in the fenced yardI will walk it on leashI have a doggie door, so it can come and go as it pleasesI have a "tie-out" trolley or stakeI use “puppy pads” so it doesn’t have to go outOther
    How will this pet get most of it's exercise?
    Section IV: About Your Other Pets Please list breed, name, sex, age and spayed or neutered for your current pets:


    Are all pets current on vaccinations? YesNo
    If not, please explain:
    Please tell us about your experience with your past or current pets. What was your biggest behavioral, medical, or financial challenge in caring for them?

    What brands of heartworm preventative and flea/tick control do you use for your pets?

    Have you ever participated in obedience training with a pet? YesNo
    Are you willing to take the adopted pet to obedience training if need be? YesNo
    Section V: About Your Desired Pet What is your gender preference for a pet? MaleFemaleEither
    What age range would you prefer?
    What size pet would you prefer?
    Would you consider a bonded pair? YesNo
    Would you consider a senior pet? YesNo
    Would you consider an incontinent pet, or one that needs remedial house-training? YesNoMaybe
    Would you consider a wheelchair pet? YesNo
    Would you be willing to adopt a “special needs” (blind, deaf, sick, 3-legged, needs daily medication, overly shy) pet? YesNo
    If yes, what kind of special needs would you consider?
    Would you be willing to work with a behavioral problem? YesNoMaybe
    Is there a pet characteristic or behavior that you do NOT want?
    Do you have a temperament preference? (Couch potato, Frisbee, jogging partner, quiet companion, etc.)

    Please add any information that we haven’t covered so far that will help us know you better.

    Section VI: Miscellaneous Are you applying to adopt a particular animal? What is their Name and/or ID Number?
    Did someone refer you to Rescued Rollers? If so, who was it? If not, how did you hear about us?
    Section VII: Affirmation


    Typing or signing your name(s) here constitutes a formal signature:

    Applicant signature:

    Date:

    Rescued Rollers reserves the right to refuse any applicant.
    Thank you for taking the time to fill out this application; it is essential to the adoption process. Rescued Rollers is a non-profit, tax exempt organization that desires to place these wonderful animals in loving homes and give them a second chance at a happy, healthy life. If you are patient with our process, we will try to provide you with a devoted and loving companion.
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