Adoption Application Form

PO Box 1855 Boothwyn, PA 19061 877-BLIND-01 www.blinddogrescue.org

Thank you for your interest in adopting a dog from our rescue. Please answer ALL questions to the best of your ability (please put n/a if not applicable). Missing information may cause a delay in processing your application. Please submit your application using a computer. The application site is not as smart as your smartphone and does not always process an application from that source.

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 who are OLDER than 21

	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship

Please list all members of the household UNDER the age of 21 and their age

	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship
Name	Name	Age	Relationship

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 yes, what type of fence do you have and how high is it? Please note BDRA has adopted a policy against electric fences being used with any BDRA dog. *

Do you have a pool? *

Yes

No

If yes, is the pool fenced in or access otherwise blocked? *

Do you have a doggy door? Please note that having a doggy door does not automatically disqualify you from adopting *

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 how many

If more than 2 cats, how many? *

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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Are all of your animals either spayed or neutered? 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 two 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: *

0/255 characters

Relationship *

Please list any questions or concerns here:

Where did you hear about us?

If an event or other please specify *

I understand that there is an adoption fee of $400, which partially defrays BDRA's costs of a vet check and any needed medical care.

I understand that for unaltered animals there is an additional one hundred dollar ($100.00) spay/neuter deposit that is refundable upon BDRA receiving proof of spay / neuter and rabies vaccination.

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 an electric fence may not be used with any BDRA dog at any time.

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

*

I agree