Adoption Application | Rescue Well

Today's Date

Interested In *

Please Fill in Name of Animal

Name *

Birthdate *

Do you have a spouse or significant other living with you?

Yes

No

Spouse/Partner

Spouse/Partner Birthdate

Address *

Phone *

Email *

Do you agree to allow a volunteer to visit your home to determine if your home is a positive environment for a pet?

Yes

No

Have you EVER been charged with animal cruelty or animal neglect?

Yes

No

Please explain any charges

In the past 10 years, have you had any pets that were lost, stolen or given away

Yes

No

Please Explain if Lost, Stolen or Given Away

Under what circumstances would you surrender (give up) a pet, explain in detail: (Examples: new baby, divorce, marriage, new pet, illness, moving, etc)

If you are adopting a cat, do you plan on declawing the cat?

Yes

No

Do you have children or anyone else residing in your home?

Yes

No

Names and Ages of Residents

Have your children lived with pets in the past?

Yes

No

How will you teach your children the correct way to interact and respect your pets?

Do all members in your household agree upon this adoption?

Yes

No

Is anyone in your home allergic to animals of any species?

Yes

No

Do you have any pets currently residing in your home? *

Yes

No

List each animals name, breed, sex and age below:

Are your current pets up to date on vaccines?

Yes

No

If not, which ones, and explain why not:

Are your current pets spayed and/or neutered?

Yes

No

If not, which ones are not spayed/neutered, explain why

Are your current pets on Heartworm Prevention?

Yes

No

Please list your current Veterinarian’s name and contact information:

Do you agree that whichever pet you adopt will be kept as indoor family pet?

Yes

No

Do you agree to feed each pet daily with fresh water and healthy food?

Yes

No

Do you own or rent? *

Own

Rent

Please list your landlord or property owner's name & contact information below:

Do you have any breed or weight restrictions with your landlord, property owner, homeowners insurance or HOA? *

Yes

No

Do you have a yard? *

Yes

No

What do you plan to do for bathroom breaks and exercise needs?

If so, is your yard securely fenced in?

Yes

No

If so, please describe fence type and height (i.e. chain link, wood, split rail)

What is the maximum number of hours this pet will be left alone during the day?

Are you employed?

Yes

No

Retired

Employer Name and Address:

How long have you worked there?

Do you have any obedience training knowledge?

Yes

No

Do you understand that it takes time for an animal to adjust to its new surroundings and behavioral issues may occur? *

Yes

No

What behaviors do you consider unacceptable behavior in a pet and how will you work on these issues? *

Are you willing to allow a 60-90 day adjustment period for your new pet to adapt to your home, your family, your routine and any other pets? *

Yes

No

Are you dedicated to correcting these issues through positive reinforcement or obedience classes? *

Yes

No

Many prospective adopters are surprised at the cost of food and medical expenses that are necessary to keep an animal in good health. During the first year you should expect to spend $300 - $500 for routine healthcare. Are you willing to make this financial commitment? *

Yes

No

Do you agree to provide for this animal for the entirety of his/her life? *

Yes

No

Please list 2 personal references (no relatives) who you have known for at least 5 years (include phone number and email address). *** Please be aware...Incomplete or empty reference fields will cause your application to be returned or denied.***

Reference 1 *

Reference 2 *

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