MAD Rescue of WNY Adoption Application

Make a Difference Rescue Adoption Application

Making a Difference for the Homeless Dogs of Puerto Rico
Name of the dog you want to adopt*
Adopter's Name*
First & Last Name
Co-Adopter's Name
First & Last Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Adopter's E-mail*
Co-Adopter's E-mail*
Phone Number*

Area CodePhone Number
Phone Type*

CellHomeWork
Names and ages of all permanent residents of your home (adults/children)*
Current pets in your home..Species, Breed, Name, Age, Sex and are they spayed/neutered?
Have you ever had to surrender, rehome or euthanize a pet and if so please explain the circumstances?
Vet reference (please call your vet and give permission to release information to us)*
Vet name, address & phone number
Are you planning to move in the near future?*

YesNo
If moving soon, to what city/state?
When will you be ready to adopt this dog?*

TodayThis weekendWithin a weekWithin a monthNot ready yet, just researching
Are you in contact with any other rescues or shelters about a specific dog?*

Yes, application is pendingYes, just an email inquiry, no app yetNo, but I am looking at several dogs onlineNo, I am only interested in this particular dog
Are you going to meet another dog?*

YesNo
If so, when?
Is anyone in your home allergic to dogs?*

YesNo
Does anyone in your home fear dogs?*

YesNo
Does anyone in your home smoke?*

YesNo
Are you familiar with dog regulations in your area?*

YesNo
If you answered no to the question above, please contact your town/county/condo assoc and ask them what the regulations are.
If yes, please describe local dog regulations and restrictions:
I/We live in a*

Single Family HomeDuplex/TwinCondo/TownhomeTrailerApartment
Do you rent or own this property?*

RentOwn
If you rent, you must show us a written letter from your landlord or a copy of the section of your lease stating that you are allowed to have dogs and showing any limitations.

If you live in a condo or townhome, you must show us written proof that you are allowed to have a dog there and show any restrictions.
Do you have a yard?*

Yard, fenced with a vertical fenceYard, fenced with invisible fencingYard, no fenceNo yard (apartment/condo/townhome)
If fenced, fence height is:

2' high3' high4' high5' high6' high
If you do not have a fenced yard how will you provide exercise, or let your dog out to potty?
Do you work outside the home?*

YesNoOne applicant is home/works from home
If one or both of you work outside the home, please list your employer and how many hours per day you are away?
How many hours per day will this dog be alone? Where will it spend its time when you are not at home?*
Have you discussed this adoption with all members of your household?*

YesNoYes, adults have discussed. Kids don't know yet.
Based on the description in the dog's bio, do you feel pretty confident that you will be likely to adopt this dog upon meeting it?*

YesNoNot sure
Upon meeting the dog, what would give you cause to not want to adopt it? Please explain.*
Fantasy question: What would your dream dog be like? (If this dog is not a fit, we may be able to recommend another based on what you say here.)*
How much do you feel you can reasonably afford and would be willing to spend on your dog per year (for things like veterinary care, licensing, ID tag, food, toys, crate, other supplies, training, pet sitting, etc)? *
What activity level do you prefer?

Wild and crazyLeash trained daily jogging partnerMedium energy, plays a bit then settles downLow energy, walks slowly on leash, a couch potato
Please check all that apply. I want to adopt this dog...*

As a family petTo breed with my dogTo train/use for huntingTo train/use for agilityTo train/use as a therapy dogTo train/use as an assistance dog for the disabledTo use as a guard dogFor a jogging/hiking partnerTo interact with lots of friends/familyAs a gift for a friendAs a companion for my dog(s)As a companion for my cat(s)As a companion for my child/children
Please check all that apply. My adopted dog will...

Be kept outside most of the timeBe kept indoors most of the timeBe left outside during the work day while we are awayBe kept inside while we are awayBe crated when we are not homeHave free reign of the house when we are not homeBe taken to formal obedience classesBe trained by me/usTake frequent car rides with usBe kept on a lead line/cable in the yardBe mostly interacting with adultsBe interacting frequently with children under 8Be interacting frequently with older childrenMust be housebroken prior to adoptionWill be housetrained by usWe be walked more than one mile per day every dayWill be walked occasionallyBe attending formal group obedience classes with usBe trained by us without the advice of a trainerHave private sessions with a trainer as neededBe taking frequent car rides/trips with usBe boarded when we go on vacationStay with family when we go on vacationBe given away to someone else if we feel it's not a good match for usBe turned in to a shelter if we can't keep itBe going camping with us
Adopting a rescued dog may come with various unknown behavioral issues. We NEVER guarantee that a dog is housebroken and ALL adopters must be prepared for and committed to some degree of housebreaking. Are you 100% committed to:*

HousebreakingSeeking the advise of a behaviorist for help with unwanted behaviorsObedience training if behavior warrants itAllowing a 2-3 week decompression period upon adoption so that your dog can gain confidence in its new home and become comfortable with its new environment and bond with its new family before exposing it to new people, outside animals, other strange environments.Extreme patience for at least the first month while your dog adjusts to its new life and understand that unwanted behaviors may happen as the dog transitions to its new normal.I will do whatever it takes to help this dog adjust and work with a trainer to help resolve any training needs.
Please think honestly about what you are absolutely NOT willing to deal with during the lifetime of your new dog.

Fear of menFear of WomenFear of childrenMouthiness( may sometimes snag your hand or arm instead of a toy in play and will need directional training)BarkingRough PlayHigh Activity LevelFood/Toy aggression with other dogsFood/Toy aggression with peopleWhining/cryingSeparation anxietyCar sicknessGiving regular flea and tick preventionGiving regular heartworm prevention
What would cause you to return a dog?*
What do you feel is a reasonable amount of time for a dog to adjust to life with you/your family?*
How do you plan to integrate this dog into your family?*
Do you plan to get pet health insurance?*

YesNoI wasn't aware this was available. I will look into it.
What brand of dog food do you plan to feed?*
Grooming (please check all that apply)*

We use a professional groomerWe trim dog nails ourselves at homeWe bathe our dogs at home once a weekWe bathe our dogs at home once a monthWe bathe our dogs at home once every few months or whenever their coat feels dirtyWe bathe our dog twice a yearWe don't bathe our dogWe check ears weekly for infection/yeast/mitesWe check coat daily for ticks in spring/summer/fallWe clean teeth using home methodsWe take our dogs to the vet for dentals whenever the vet recommends this is neededPrefer a dog that doesn't shedDon't care about shedding
How long have you been looking for a dog?*
How do you feel about having pets spayed/neutered?

AgreeDisagree
Are you familiar with heartworm and heartworm prevention?

YesNoSomewhat but would welcome more information
Additional reference (if desired)
Do you have any additional comments, questions or concerns? Anything else you would like us to know to help match you up to a dog?*
Please read the above, check this box, sign, and click Submit.

I/We have read and understand all of the above.
Applicant's Signature*
Co-Applicant's Signature
Signature date*
After you submit this form, it will take you back to the Make a Difference Rescue home page. Feel free to email us with any questions: madrescueofwny@aol.com
Please verify that you are human*
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Make a Difference Rescue Adoption Application