Adoption Application

Canine Companions Adoption Application

Name:__________________________________ D.O.B. _____________ Gender: M / F

Address: _______________________________________________________ Apt #: ____________

City: ________________________________________ State: ____________ Zip: ______________

Phone #: ______________ Alt Phone #: ______________ Email: ____________________________

I currently Rent / Own my residence. There is a K9 size restriction in our building. Y / N

If yes, what is the maximum weight / height allowed? _____________________________________

If Rent; Landlord name: _______________________________________ Tel # _________________

Annual household income: ____under $24k / ____ $24k - $35k / ____ $35k - $50k / ____ $50k +

I am currently employed? Y / N Average number of hours I work each week __________

If no, I am not currently because I am: _____ Retired / _____ Out of work / _____ Unable to work

I currently have a disability: Y / N If yes, what is the nature of the disability? ____________

_________________________________________________________________________________

Do you feel your disability may prevent your ability to care for your canine in any manner? Y / N

If yes, how so? ____________________________________________________________________

Do you have children living with you? Y / N Do children visit your home? Y / N

If yes to either, please list the first names and ages:

________________________________________________________________________________________

Do you currently have any pets in the residence? Y / N If yes, how many? _____________

If yes, please list type(s), age(s). ______________________________________________________

________________________________________________________________________________

Are you willing to allow a Canine Companions representative perform an assessment of your home to help us select the best suited match for your living environment. Y / N

Desired canine size:

_____ under 15 lbs _____ 15 – 30 _____ 30 – 50 _____ 50 – 75 _____ 75 – 100 _____ 100+

Requirements:

Do you feel that you are adequately capable of caring for a canine companion in the following manner?
1. Provide food and water daily   _____ Yes    _____ No
2. Provide a place that allows for regular potty visits   _____ Yes    _____ No
3. Possess the ability and willingness to cleaning up potty area   _____ Yes    _____ No
4. Possess the ability and willingness to provide exercise on a regular basis   _____ Yes    _____ No

As a Canine Companion adoption candidate you must adhere to the following conditions.
1. Be willing to accept the type and size of dog the Canine Companions staff member recommends based on the living environment and ability to provide care.
2. Interact with adoption candidate prior to adoption approval.
3. Attend obedience classes at our facility with you future companion.
4. Allow our canine adoption candidate and Canine Companions staff member to spend time at the adopting parent’s residence periodically prior to taking custody of the animal.
5. Provide a healthy and loving environment for their companion.
6. Maintain updated vaccinations and cover all required veterinarian expenses.
7. Have a plan in place should they become unable to continue their adoption commitment.
8. Able to manage the cost of feeding and maintaining a good quality of life for a canine companion.

Prior to custody, you will be required to spend time at our facility getting to know your future companion. During that time you and your companion will be required to attend obedience training classes. What day(s) works best for you? (Check all that apply)

____ Sun ____ Mon ____ Tue ____Wed ____ Thu ____ Fri ____ Sat

What time of the day works best for you? (Check all that apply)

Morning _______ Afternoon _______ Evening _______

Have you owned a canine companion in the past? If yes, when and what breed(s)?

_______________________________________________________________________________________

By signing below you agree to all of the terms and conditions associated with our adoption program. Also, please be advised that Canine Companions reserves the right to reject or terminate any candidate or adoption at any time during or following the adoption process for any reason deemed detrimental to the companion animal or any aspect of our organization or staff.

___________________________________________   ____________________________________
Candidate signature / Date             Alternate Care Giver / Date

___________________________________________ ____________________________________
Canine Companion Representative / Date ACG Approval Signature / Date

Additional note or comments:

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