Adoption Application - Rescue Warriors Corp.

General Information

Applicant Name:*

First

Last

Applicant Age:*

Co-Applicant Name:

First

Last

Co-Applicant Age:

Home Phone:*

Area Code

Phone Number

Cell Phone:*

Area Code

Phone Number

Residential Address: (Not a P.O. Box)*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Best time of day to contact you:*

AM/PM

E-mail:*

Years at Residence:*

Distance willing to travel to adopt (Note: minimum 250 miles or more may be required):*

Number of Residents in Household:*

Name of Pet your are willing to adopt:*

Pet age you are willing to adopt?*

Puppy only

Adult only

Either

Must the pet be good with children?*

Yes

Are you willing to adopt a special needs pet?*

Yes

What level of special needs would you accept?:

MINIMAL (Daily medications, special food, etc.)

MODERATE (Frequent medications, house training issues, difficulty walking, behavior issues, etc.)

SEVERE (Blindness, deafness, incontinence, seizure disorder, etc.)

Applicant Employment Information

Occupation:*

Employer Name:*

Address:*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Employer Phone:*

Area Code

Phone Number

Co-Applicant Employment Information

Co-Applicant Occupation:

Co-Applicant Employer Name:

Co-Applicant Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Co-Applicant Employer Phone:

Area Code

Phone Number

Household Member's Information

Name, age and relationship of all members of household:

Are there children in the home?*

Yes

Number of children in your home?

Do children visit the home?*

Yes

Ages and frequency of visits:

Are you willing to supervise the pet at all times with children under the age of 10?*

Yes

Is anyone in the household allergic to pets?:*

Yes

Who will be responsible for caring for the pet?*

First

Last

Dwelling Information

Housing Type:

Rent or own?*

Rent

Own

Does your landlord, condo/homeowner's association, or local municipality have any pet restrictions such as weight limit or number of pets? *

Yes

Note: If you live in a condo, the Association contact information is required. We must contact your association to verify that you are allowed to have pets.

Condo Association Phone:*

Area Code

Phone Number

Note: If you rent, the landlord contact information is required. We must contact your landlord to verify that you are allowed to have pets.

Landlord Name:*

First

Last

Landlord Phone:*

Area Code

Phone Number

How will the dog be exercised, how often, and who will supervise the dog while outdoors? Please descibe:*

Please confirm that you have checked for any restrictions and describe them if any apply. If there are no restrictions, please enter "NONE".

Do you have a fully enclosed fenced ?*

Yes

What type of fence?*

Height of fence:*

Are all household members in favor of adopting a pet?*

Yes

Does your home have stairs that the pet will have to go up and down?:*

Yes

Please describe stairs and how many:*

Do you have a swimming pool, pond (including ornamental ponds), in-ground hot tub, lake, river, or any body of water in or near your residence?*

Yes

Is there a secure fence to keep the pet out?:*

Yes

Is your home air-conditioned?*

Yes

Air-conditioning type?*

Is your car air-conditioned?*

Yes

Lifestyle

What five words best describe your family?:*

Please describe any changes you expect in your household in the next few years; e.g. new children, job changes, moving, etc.:*

How soon will you be ready to adopt a pet? (Please check applicable):*

Immediately

Next 3 Months

Next 6 Months

More Than 6 Months

Are any family members home during the day time? (Please check applicable):*

All Day

Most Of The Day

Sometimes

Seldom

Are you involved in any pet store, commercial dog breeding operation, or buying dogs for resale?:*

Yes

Have you ever been convicted of cruelty to animals?:*

Yes

Have you applied to adopt with any other Rescue Organizations?:*

Yes

If yes, which ones?:

Pets (Current and Past)

Veterinarian's address:*

Have you ever owned a pet?:*

Yes

Do you currently own any dogs?:*

Yes

Do you currently own any cats?:*

Yes

Please list any pets (all dogs, cats, and others) owned now or in the past 5 years:*

Type/Breed:

Age/Gender:

Spayed/Neutered?:

Where are they now?:

Type/Breed:(1)

Age/Gender:(1)

Spayed/Neutered?:(1)

Where are they now?:(1)

Type/Breed:(2)

Age/Gender:(2)

Spayed/Neutered?:(2)

Where are they now?:(2)

Type/Breed:(3)

Age/Gender:(3)

Spayed/Neutered?:(3)

Where are they now?:(3)

Type/Breed:(4)

Age/Gender:(4)

Spayed/Neutered?:(4)

Where are they now?:(4)

Type/Breed:(5)

Age/Gender:(5)

Spayed/Neutered?:(5)

Where are they now?:(5)

Have you ever given a pet to a rescue organization or animal shelter?:*

Yes

If yes, please describe the circumstances:

Have you ever had a dog that has bitten someone?:*

Yes

If yes, please explain the circumstances:

Do all of your current pets get along well with other animals?:*

Yes

If no, please explain:

Do all of your pets receive regular veterinary care (including heartworm testing and heartworm preventative) and are they up-to-date on vaccinations?:*

Yes

What heartworm preventative do you use?:*

If you have adopted from a rescue before, please provide details:

Veterinarian Information

Your veterinarians name:*

Veterinarian's street address:*

Veterinarian's City, State, Zip Code:*

Veterinarian's phone number:*

Pet Care Philosophy

Can all household members travel to the rescue group to meet the prospective adoptee?:(1)*

Yes

Are you willing to work with the rescued pet to resolve problem behaiors? (e.g. chewing, pulling on lead, barking):*

Yes

What type of behavior in a dog would make you not want to adopt him or her?:*

How will you correct behavior problems?:*

Do you understand that rescued pets may have house-training problems, especially at first while adjusting?:*

Yes

Please describe what you know about common health problems with the breed you are trying to adopt:*

How much to you expect to pay per year to take care of your new pet?:*

Who will take care of your pet during vacations or overnight trips?:*

Can someone in the household provide daily care when the primary caregiver is away?:*

Yes

Do you have an emergency plan to provide care for your pets if you have to leave town suddenly?:*

Yes

If yes, please describe:

What do you feel is the proper use of crates or cages?:*

Agreements/Understandings

Can all household members travel to the rescue group to meet the prospective adoptee?:*

Yes

Are you willing to take responsibility for the pet for its lifetime?:*

Yes

Do you agree to have a rescue volunteer inspect your home before and/or after an adoption is completed?:*

Yes

All pets adopted from us will be spayed/neutered before placement including puppies. Do you have any questions or reservations about this policy?:*

Yes

If yes, please explain:

Puppies under the age of four months require a series of three to four vaccines before being considered fully immunized. Adult pets will require yearly booster vaccines. Are you prepared to provide this needed care for an adopted puppy? *

Yes

Often times, pets coming from a shelter environment will require continued medical care to treat and/or prevent intestinal parasites. Are you prepared to provide this needed care for an adopted pet? *

Yes

Dogs who are from shelters have a higher risk of exposure to illness due to the amount of animals they are potentially exposed to. Rescue Warriors Corp. makes every effort possible to ensure the health and well being of it’s adoptable pets. Once in a while, despite best efforts, a pet will become ill post adoption. Pet insurance is provided that typically helps to cover the cost of minor health issues. Adopters are responsible for the deductible and signing up for this insurance offer after adoption. As a non-profit organization, any bills you incur at your private veterinary clinic will not be repaid. Do you understand the health and treatment policies of Rescue Warriors Corp.?*

Yes

Additional Comments

I understand that the adoption fee is non-refundable:*

Yes

I understand that Illinois Rescue Warriors Corp has the right to refuse any placement with a potential adoptive home:*

Yes

I understand that dogs placed by the Rescue Warriors Corp have been acquired, fed and boarded by RWC volunteers; have received medical care and vaccinations; and have tested to be free of heartworms and contagious disease at the expense of RWC who receives financial reimbursement for expenses only through donations. I understand that I may be asked to give a donation to RWC to help with the spaying/neutering and veterinary care of current and/or future rescued dogs/cats:*

Yes

Signature:*

Date*

PLEASE BE SURE TO NOTIFY US IMMEDIATLEY SHOULD YOUR SITUATION CHANGE OR YOU ADOPT ELSEWHERE.