Sunshine Golden Retriever Rescue

Senior Adoption Application Form

	01. Your First and Last Name
	02. Your Age - must be 21 years old & up
	03. Co-Applicant Name
	04. Co-Applicant Age
	05. Relationship to Applicant
	06. Your Address
	07. Your City
	08. Your State
	09. Your Zip
	10. Your Email
	11. Home Phone
	12. Work Phone
	13. Cell Phone
	14. Your Employer
	15. Your Occupation
	16. Your Work Schedule
	17. Co-Applicant Employer
	18. Co-Applicant Occupation
	19. Co-Applicant Work Schedule
	20. How did you hear about us?
	21. What is your time frame for adoption?
	22. Where else have you applied?
	23. Why do you want a Rescue Golden?
	24. Dog Sex		Select Male Only Prefer Male Female Only Prefer Female No Preference
	25. If sex is required, please explain
	26. Dog Age - you can select more then one		6 to 7 7 to 8 8 to 9 9 to 10 10+ Senior No Preference
	27. Dog Size - you can select more then one		Small (45 to 55) Medium (55 to 65) Large (65 to 80) X-Large(80 Up) No Preference
	28. If size is required, please explain
	29. Would you accept a Golden Mix		Select Yes No
	30. How important is it that a dog who is a mix “looks Golden”?
	31. Would you accept a Golden Hearted dog who did not look mostly Golden		Select Yes No
	32. Would you be interested in adopting a bonded pair?		Select Yes No
	33. List in order of importance the characteristics you want in a dog
	34. Check the behaviors or characteristics that are not acceptable		Jumping Chewing Mouthing Timid/Scared High Energy Alpha/Dominant Counter Surfing Requires Fencing Excessive Barking Not House Trained Not Leash Trained Separation Anxiety Issues Needs Obedience training Medication Dependent - Seizures, Thyrod Physically Handicapped - 3 legs, 1 eye
	35. Have you ever owned a Golden Retriever before		Select Yes No
	36. Have you ever owned a rescue dog?		Select Yes No
	37. From where did you rescue your previous dog?
	38. How many dogs have you owned as an adult?
	38a. Pet #1 Name
	38a. Pet #1 Type
	38a Pet #1 Age		Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
	38a Pet #1 Sex		Select Male Female
	38a Pet #1 Where is this pet now?
	38b. Pet #2 Name
	38b. Pet #2 Type
	38b. Pet #2 Age		Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
	38b. Pet #2 Sex		Select Male Female
	38b. Pet #2 Where is this pet now?
	38c. Pet #3 Name
	38c. Pet #3 Type
	38c. Pet #3 Age		Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
	38c. Pet #3 Sex		Select Male Female
	38c. Pet #3 Where is this pet now?
	38d. Pet #4 Name
	38d. Pet #4 Type
	38d. Pet #4 Age		Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
	38d. Pet #4 Sex		Select Male Female
	38d. Pet #4 Where is this pet now?
	39. Have you ever		Had a pet who became lost? Had a pet poisoned? Had an animal killed by a vehicle? Had an animal treated for a disease? Had an animal die due to disease? Sold, given away, or surrendered a pet to a shelter?
	40. If yes to any of the above, please explain in detail
	41. Do you have other animals		Select Yes No
	42. For each animal that you own, please list "Type" breed for dogs
	43. Please list "Age" for each
	44. Please list "Gender" for each
	45. Please list "Spayed or Neutered" for each
	46. What food(s) does your current dog eat?
	47. Are all pets up-to-date on vaccinations		Select Yes No
	48. If "no" please explain why not
	49. List preventative treatments current pets receive
	50. Describe your experience with training your previous dogs
	51. Where do you plan to enroll your next dog for obedience training if it is required
	52. Do you live in a		Select House Townhouse Duplex Condo Apartment Other
	53. Do you rent or own		Select Rent Own
	54. If you rent, do you have permission to keep a large dog		Select Yes No
	55. Please list your: Landlord's Name; Address; City, State, Zip, Phone Number
	56. Do you have a yard?		Select Yes No
	57. What size is your yard?
	58. Is it completely fenced?		Select Yes No
	59. What type and height of fencing?
	60. If no fence or partial fencing, how will your dog be allowed to exercise, play, and relieve him/herself
	61. How will your dog be exercised and how often do you plan to proved this exercise?
	62. How often and under what circumstances will your dog be left unattended outside?
	63. How often and under what circumstances will your dog be allowed to be off -leash?
	64. Do you have a tie out or runner for your dog?		Select Yes No
	65. If yes, you MUST explain how and when it is used
	66. Other than the applicant(s), how many adults in the household?
	67. Ages of other household members(other than applicants) and relationship to applicant(s)
	68. How will they be involved with care of the dog?
	69. How many children in the house?
	70. Ages of children in the house
	71. Who will be responsible for the care of the dog?
	72. Who will be responsible for the training?
	73. How many hours a day on the average will the dog be left alone, without adults at home?
	74. Where will the dog be kept when no one is at home?
	75. What provisions will be made for your Golden during those times?
	76. Will the dog be primarily kept		Select Indoors Outdoors
	77. Where will your Golden sleep?
	78. Will your dog		Select Be in a blocked-off portion of the house Have the run of the house Be crated Be tied or attached to runner outside Be kept in a dog house
	79. Please be specific and explain
	80. What type of dog experience do you have?
	81. How often do you travel
	82. Who will care for your dog when you are away
	83. Will this dog be a gift		Select Yes No
	84. If the dog is a gift, then for whom
	85. Does the recipient know		Select Yes No
	86. Does your household want to get a rescue Golden		Select Yes No
	87. Are you willing to travel more than 2 hours to pick up your dog		Select Yes No
	88. Are you planning to move in the near future		Select Yes No
	89. Whenever you DO move, what will you do with your dog
	90. Is anyone in your household allergic to animals		Select Yes No
	91. If they are allergic, please explain
	92. Are you willing to allow a rescue volunteer to complete a home visit in order to approve adoption and at least one follow up after adoption		Select Yes No
	93. Do you accept that the total adoption fee for dogs is:		Select Yes No
	94. Would you be willing to adopt a dog directly without meeting him or her first		Select Yes No
	95. Do you agree to contact your vet within 24 hours of this application to authorize release of information to SGRR		Select Yes No
	95a. Current Vet Name
	95b. Current Vet Address
	95c. Current Vet City, State, Zip
	95d. Current Vet Phone
	96a. Past Vet Used Name
	96b. Past Vet Used Address
	96c. Past Vet Used City, State, Zip
	96. Please use this space to tell us anything about you which you think may be helpful.
	97. Tell us what dog(s) you're interested in
	98. Do you agree to the following		Adoptions are completed with the signing of an adoption contract; Under the terms of the contract, a SGRR dog may never be given away or sold and MUST be returned to SGRR in the event you are no longer able to care for the dog; Your rescue Golden will be kept on heartworm prevention for the first 12 months you have him/her, and as recommended by your vet thereafter;
	99. Do you understand that we reserve the right to remove a dog at any time should we find the adopter is no longer caring for their Golden in a way we see fit.		Select Yes No
	100. We also require adopters to agree to follow up visits as needed.		Select Yes No
	101. By submitting this form I hereby authorize a SGRR representative to verify all information		Select Yes No
	102. All of the information I have given in this questionnaire is true and complete		Select Yes No
	103. By entering my signature here, means I have agreed to all the terms in this form*		Select Yes No
	104. I understand that submission of an application DOES NOT guarantee a dog will be placed with me*		Select Yes No
	105. Applicant's Signature*
	106. Date of Applicaton*
	107. Your Email*