DRSWV Adoption Application

Dalmatian Rescue of Southwest Virginia Adoption Application
The information we request in this form is to ensure that we are finding a quality permanent home for our Dalmatians. This information assists us in achieving the best possible match between a dog and a potential new owner.
What puppy/dog are you interested in adopting (or age, color, sex) & why?*
Your name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your email*
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Best time of day to be contacted*
Names and ages of all permanent residents of your home (adults/children)*
If applicable, will your children be taught how to play gently and kindly with this animal?*
If no children, do any ever visit (ages)?*
What type of home do you live in?*

HouseApartment/CondominiumManufactured home
Do you own or rent your home?*
If you rent , please provide your landlord/renting agency's phone number*
How long have you lived at this residence?*
Do you mind if we conduct a home visit prior to or after adoption?*

NoYes
Are you looking for a dog as a:*

CompanionWatchdogPlaymate for another dogPlaymate for a childGift for another person
Describe your yard & fencing (type, height, size of fenced area, completely enclosed? Shade in the yard?)*
Will the dog be left outside unattended? If yes, for how long?*
If no fence, how will the dog be let outside?*
Is anyone home during the day?*

YesNo
How many hours would the dog be alone?*
Where will the dog be housed during the day? At night?*
Where will the dog stay when home alone?*
Do you own or have you ever used a crate?*

Yes, own & have usedNo, but have used oneDo not own & have not used
Please list all pets currently living in your home along with their age/breed and if they are altered*
What other pets have you had in the last 5 years?*
Why are they currently not with you?*
Have you ever surrendered or returned a pet to a shelter?*

YesNo
Have you ever given away or sold an animal?*

YesNo
If yes to either question above, please explain
What would you consider a reason for not keeping a puppy/dog?*
Rescued animals need time to adjust to their new home. How long are you willing to give this puppy/dog to adjust?*
Puppies/dogs sometimes chew furniture, shoes, woodwork, etc., how would you manage this problem?*
Describe the dynamics in your household (busy/quiet). How many hours a day will the puppy/dog be alone?*
Have you or anyone in the household ever owned a Dalmatian?*

YesNo
Do all of the adults in the household agree to adopting the dog?*

YesNo
Does anyone in your house have pet allergies?*

NoYes
Do you use parasite prevention?*

YesNoExplain:
What kind of heartworm & flea/tick prevention do you use?*
If you currently have a dog, what type (wet/dry) & brand of food do you use?*
How often do you feed?

1 x per day2 x per daySelf feeder
If you go out of town on vacation, who will care for your animal?*
If something were to happen to you, do you have a plan in place for your pets?*
What Veterinarian do you use? Name/phone number (with area code)*
May we contact your Veterinarian?*

YesNo
If no current Veterinarian, name & number of one you have used in the past.*
If no Vet at all, please provide names/numbers of 2 personal references (other than relatives).*
Vet bills can be expensive. How do you plan on paying them? (IE: Pet health insurance, savings, Care Credit)*
Do you have additional comments, questions or concerns?
By clicking the box below, you agree to & understand the terms of this form.

1. If I am approved for adoption and I cannot keep the dog for any reason, it will be returned to Dalmatian Rescue of Southwest Virginia immediately.
2. I am authorizing, through submission of this form, the Veterinarian(s) named above to release any information and records concerning past or present care of animals to Dalmatian Rescue of Southwest Virginia. I agree to hold harmless and indemnify said Veterinarian(s) for providing such information.
3. I have not, nor has anyone in my household, ever been charged with any forms of animal abuse, neglect or cruelty.
4. I am at least 18 years of age and I have read this application in its entirety and have answered each question honestly and to the best of my ability.

Dalmatian Rescue of Southwest Virginia debi.smith@drswv.com
Applicant's signature*
Co-applicant's signature
Date*

MonthDayYear
Thank you for taking the time to submit this form.

Please feel free to contact DRSWV with any questions. After you click the Submit button, you will be redirected to the main page and you will receive a confirmation email.
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Dalmatian Rescue of Southwest Virginia Adoption Application

The information we request in this form is to ensure that we are finding a quality permanent home for our Dalmatians. This information assists us in achieving the best possible match between a dog and a potential new owner.