Blind Dog Rescue Alliance Adoption Application Form

PO Box 63401 Philadelphia, PA 19114 877-BLIND-01 www.blinddogrescue.com

Thank you for your interest in adopting a dog from our rescue. Please answer all questions to the best of your ability. Missing information may cause a delay in processing your application.

First Name

Last Name

* Address 1

Address 2

* State

* City

* Zip

Cell phone

* Home phone

Best time to call?

Email address

Occupation

*

Are you interested in adopting a particular dog on our site?

Yes

No

If so, which one, and why do you want to adopt this dog in particular?

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*

If this dog is not available, would you consider another?

Yes

No

Any specifics, such as breed, sex, or size?

* Is everyone in the household agreeable to this adoption?

* Does anyone in the household have allergies to dogs?

Please list all members of the household

	Age	Relationship
Name
Name
Name
Name
Name
Name
Name

* Who will be the primary caretaker of the dog?

* How many hours a day, on average, will the dog be alone?

* Where will the dog stay during this time?

* Who will take care of the dog when you are away?

* Where will the dog sleep at night?

* Do you own or rent your home?

If renting are pets allowed?

Yes

No

Landlord's name and phone number

Please give your landlord permission to speak with us and answer our questions

* Do you have a fenced in yard?

Yes

No

If no, how do you plan to exercise and toilet your dog?

* Do you currently own other pets?

Yes

No

Current Pets

Please list any dogs you currently own:

Name

Sex

Age

Breed

Name

Sex

Age

Breed

Name

Sex

Age

Breed

If more than 3, please list here.

* How many dogs have you owned in the past 10 years that are no longer with you?

Please describe what happened to them:

* Do you own any cats?

yes

no

If so, how many?

1

2

more than 2

If so, do you know if they are dog friendly?

* Do you own any other animals?

yes

no

If so, please list:

Are any of your pets visually impaired?

Yes

No

* Do your pets visit your veterinarian at least once a year for a checkup?

Yes

No

* Are they up to date on vaccines? If not, please explain:

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Name of Vet/Clinic

Please provide the following information about your veterinarian, if you have one:

Full address and phone number

Please call your vet and give permission to release information to us.

* Have you ever given away any of your animals for any reason?

Yes

No

If yes, please explain:

* Have you ever lived or worked with a blind or visually-impaired dog?

Yes

No

If not, why did you choose to do so now?

* Have you done or do you intend to do any reading in preparation for adopting a blind dog? Please specify:

* Do you plan to do any training with your new blind dog? If so, please specify:

* Do you understand and accept that changing a dog's environment, may cause the dog to have accidents, especially in the early days of the adoption?

Yes

No

* Are you willing to take the time to work with a pet on housebreaking issues should the need arise?

Yes

No

* If a behavioural problem arises, what steps will you take to work on it?

* Do you agree to a home visit by a representative of BDRA prior to adoption?

Yes

No

* If, for any reason, you are unable to keep the dog, do you agree to notify BDRA immediately?

Yes

No

* Do you also agree to return the dog to BDRA at your own expense?

Yes

No

Please list 3 references, preferably who have known you more than 2 years (only one family member).
Please let them know that you have listed them as a reference and give them permission to answer our questions.

* Name 1

* Address, and phone number:

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* Relationship

* Name 2

* Address, and phone number:

0/255 characters

* Relationship

* Name 3

* Address, and phone number:

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* Relationship

Please list any questions or concerns here:

*

I understand that there is an adoption fee of $200, which partially defrays BDRA's costs of a vet check and any needed medical care.

I certify that I am at least 21 years of age and that I will be the legal owner of, and ultimately, solely responsible for the care and well-being of any dog I adopt from BDRA.

I understand that any misrepresentation of the true facts in this application or in the adoption agreement will invalidate the adoption agreement and will give BDRA the right to reclaim the dog without refund of the adoption fee.

I understand that by clicking “Submit” below, I agree to all of the above.

I agree

* Indicates Response Required


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