Adoption Application

Name:

Address:

City:

State:

Zipcode:

Home Phone:

Work Phone:

Best time to call:
Morning
Afternoon
Evening

E-Mail Address:

Name of dog(s) from our site who you like:*

1) Why do you want to adopt a dog:

2) What do you think are the most important responsibilities in having a dog:

3) Are you adopting the dog for you/your family, or for someone else:

4) Does everyone in your household know you are applying to adopt a dog, and does every member of your household want a dog:
Yes
No

5) Please describe those pets who are currently with you:

type, age, gender, spayed/neutered

6) Please describe those pets who are no longer with you:

type, age, gender, spayed/neutered

7) Why are these pets no longer with you:

please be specific

8) Does anyone in the household have allergies to pets:
Yes
No

9) How many people resides in your household? Please list name and age of each:

10) Please provide the name, address, phone number of the veterinarian for your pets:

If you had pets in the past, please list info for the vet you used. If you do not currently have a pet, please provide info for the vet you intend to use if you adopt a dog

11) Who will be responsible for feeding, house breaking/training:

12) Do you own or rent your residence:
Own
Rent

13) If you rent, please provide the name, address, phone number of your landlord:

14) What type of home do you live in:
Condo
Single family dwelling
Apartment
Manufactured house

15) Is your yard fenced:

15-a) If yes, please state the approximate size:

15-b) What kind of building material is the fence made from:

15-c) What portion of the yard is fenced and how high is the fence:

16) If you have no fence, how do you plan to keep the dog at home:

17) Where will the dog stay during the day:

Please check all that apply. Use Ctrl+Left Click to select multiple options.

18) How much time will the dog spend outside each day:

hours

19) Will anyone be home during the day:
Yes
No

19-a) Who will be home during the day:

If your answer to Question 19 is Yes, Please specify who will be home during the day

20) How frequently will the adults be gone away from home on business/vacation trips:

21) When you are on vacation, where will the dog be kept:
Home, someone comes over to feed
Pet sitting service
Will board at kennel

21-a) Others:

Write down where the dog is going to be kept when you are on vacation of the above options are not relevant.

22) Where will the dog sleep every night:

23) What do you intend to feed the dog:
Dry Kibble
Wet/Canned
People/Table food

23-a) Please write down the Name brand(s) of the food you intend to feed the do:

24) How will you housebreak/train the dog:

Details please

25) How many hours a day will the dog be left unattended:

26) How many dogs have you been responsible for in the past ten (10) years:

27) What made you choose this specific breed:

28) Please list any preference(s) you have in adopting a dog:

Use Ctrl+Left Click to select multiple options.

29) Conset Release:*
Yes
No

Do you give your permission for us to contact your vet, and consent for your vet to release the information in your current/past pet(s) health files to us.

30) Is there anything you would like A Leg Up Rescue to know that you do not feel the application addressed:

Your Initials:*

I represent the information I have provided on this form is the truth to the best of my knowledge and belief, and hereby give my permission for A Leg Up Rescue to use any of the above information to confirm all information provided is the truth.

A Leg Up Rescue

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Before you can adopt a pet, you must:

Online Application Form: