BHR Dog Adoption Application

Broken Hearts Rescue Dog Adoption Application
Today's Date*

MonthDayYear
Name of the dog you are interested in:*
Adoption Guidelines:
- 18 years of age or older
- If renting - a letter stating you may have animals and any restrictions.
- If in a housing development - covenant must say you can own a pet or specific breed if applicable.
- Be able/willing to provide for the animal financially and emotionally to include time, necessary training and medical care.
- All current animals in household must be spayed/neutered unless there are medical reasons not to.
- We do not ship furkids, a meet and greet at a neutral location with all people and dogs living at the home and the furkid is required.
- A homecheck is required.
Please initial that you have read and understand the above guidelines:*
Completion of this application does not guarantee the adoption of a furkid. Broken Hearts Rescue (BHR) reserves the right to deny any application if we feel that the furkid is not a good fit for your family or environment. Please understand that we have the furkid's best interest in mind and we will place the furkids in the best home suited for them, not the first one that applies. This does not necessarily mean that your home is not suitable, but that there may be a better suited home for that particular furkid. If our representative determines that you are not the right fit for the furkid, and you would like to adopt another of our furkids, you may transfer the application to another furkid in our foster program by emailing us or talking with a representative. Our ultimate goal is to place each furkid in the best suited environment for them. Each furkid has its own personality therefore each furkid will be assessed while it is in foster care to see what type of family it will best be suited for. Keep in mind that adopting a furkid is a lifetime commitment and not a temporary one. Many of our furkids have come from less than desirable backgrounds and deserve a good, loving home that will treat them as family, not put them outside and have no contact with them. It is hard on them to be moved from home to home. Throughout the application please mark all items that apply when there are choices.
Please initial that you have read, understand, and agree to the above policies:*
Your full name:*
Other Adults Name(s) in Household
Street Address:*
City, State, Zip*
Phone:*

Area CodePhone Number
Spouse/Other Adult Phone:

Area CodePhone Number
If we need to contact you, is it okay to text?*

Yes, first number onlyYes, second number onlyYes, both numbersNo
E-mail:*
*Email is only used to contact you about the dog you are applying for.
Please make sure your email is correct and you are checking your junk folders for a response. We generally contact by email.
Employer:*
Occupation:*
Spouse/Other Adult Employer:
Spouse/Other Adult Occupation:

List all the people (including yourself) and ages that live in the home. Please fill out completely. Applications missing information will not be considered.*

	Names	Ages
1
2
3
4
5
6
7
8
9
10

Do you live in a*

HouseApartmentCondoMobile HomeLive with Family/FriendHousing Provided by EmployerOther
Do you own or rent?*

OwnRent
Does your landlord allow dogs?

YesNo
Are there any restrictions from your landlord or subdivision?*

Number of petsSize or weight restrictionsBreed restrictionsNoneOther
*If renting, a letter will be required from landlord stating pets are okay and what if any restrictions on them prior to adoption. Your application will not be processed further until that letter/email is received.
If renting, provide name and phone number of landlord:
How long at current residence:*
If less than 5 years, please list previous address:*
Do you already have pets living in the home? Even if it is a temporary situation.*

YesNo

List current pets living in the home (even if temporary) and all of their information. You may have to scroll to the right. Please fill out completely. Applications missing information will not be considered.

	Cat or Dog	Name	Age	Gender	Spayed or Neutered?	Vaccinations Current?	Size	Breed
1
2
3
4
5
6
7
8
9
10

If your current animals are not up to date on vaccinations or not spayed/neutered, please explain why.
Any household members allergic to animals? Check all that apply.*

NoYes - CatsYes - Dogs
Are you gone more than 4 hours a day where the furkid would be left alone?*

YesNo
Explain why or why not:*
Where will the furkid be housed when gone? Check all that apply.*

Inside - Free ReignInside - Wire CrateOutside - Loose in YardOutside - KennelOther
Where will the furkid be housed when home? Check all that apply.*

Inside - Free ReignInside - Wire CrateOutside - Loose in YardOutside - KennelOther
Have you submitted an application with another organization in the past year?*

YesNo
If so, who and when?
Have you ever been denied adoption of a furkid from a rescue or animal organization?*

YesNo
If yes, explain:
Who are you adopting this furkid for:*

Myself/my family living with meFamily member not living with meSurprise giftGiftOther
Why do you want to adopt THIS furkid? *
Have you sold/given away/rehomed to someone else ANY furkids (yours or not) in the past?*

YesNo
If yes, describe the circumstances:
Have any furkids passed away while in your care?*

YesNo
If yes, describe the circumstances:
Do you understand that the furkid may not be potty trained and, if they are listed as potty trained, they may have accidents in a changing environment?*

YesNo
Are you willing to work with the furkid on house training/issues that may arise?*

YesNo
Explain any personal situation that may arise to cause you to return the furkid:*
Do you have a backup plan for the furkid in case something were to happen to you? Who would take them and have you had that discussion with that person?*
Have you considered the expenses of adopting a furkid; medical/food/training/toys/etc.?*

YesNo
List two NON-FAMILY personal references:
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
Current Vet:
Fully fenced front yard?*

YesNoOther
Height and type of fence
Fully fenced back yard?*

YesNoOther
Height and type of fence
I understand that I assume full responsibility for the welfare of this pet from the date of adoption.
I have read the above information carefully and have filled out this application with true and correct information. I understand that the omission of information and/or failure to answer all questions and sign this application may result in the denial of this application. I further understand that if an untruth is discovered once the application is approved that BHR reserves the right to dissolve this application and reclaim the furkid. INITIAL:*
I understand that unless the furkid has papers that all ages and breeds are only an estimate/guess. In addition furkids will be deemed a "mix" even if they exhibit full breed traits. INITIAL:*
BHR has my permission to check the information provided in this application and further investigate if questions arise. INITIAL:*
If my application is accepted, I agree to a home/yard check and meeting with all members and dogs in the household prior to the actual adoption at a mutually agreed upon date by all parties. INITIAL:*
If selected to adopt the dog listed I understand that I will also be required to fill out an adoption contract and pay adoption fees. INITIAL:*
I understand that the adoption selection is based on the dogs needs/best suited environment for him/her and that the decision is final and therefore I/we will not argue the decision, however, I may apply for another furkid unless specifically stated otherwise by BHR. INITIAL:*
I understand that BHR cannot hold/reserve a dog while waiting on a landlord letter, other documents, or payment. Nor will I request for the dog to be held without adopting, even for a short period of time.
If electronically submitting this form I understand that my typed name serves as my signature. INITIALS:*
Electronic Signature:*
How did you find out about Broken Hearts Rescue

PetcoRescue MeFacebookFriend/FamilyBroken Hearts Rescue WebsiteOther
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Broken Hearts Rescue Dog Adoption Application