COUNTRY CLUB KENNELS & TRAINING
10739 Bristersburg Road
Catlett, Virginia 20119
(540) 788-3559 or fax:(540)788-4987
e-mail: carlacck@aol.com
Click here for a printable version
of this questionnaire.
The Chance Foundation is a recognized non-proft 501(3)(c) foundation.
Any donations are tax-deductible and very much appreciated.
ADOPTION QUESTI0NNAIRE
Date: _________________ Dog Interested In: _______________________________
Breed: ______________________ How did you hear about us?:___________________
The following are questions to help place the right pet with the right family
and to identify you.
1. Personal Information:
Name of potential adopter ____________________________________________________
Driver’s license number: _____________________________________________________
Home address where the dog will reside:_________________________________________
Phone: (Home) ______________________ E-mail address: __________________________
Your employer:____________________________ Business Phone: ___________________
Spouse’s employer: _________________________Business Phone: ___________________
2. Why have you chosen to adopt a rescue dog?_____________________________________
_____________________________________________________________________________
Why this specific dog? _______________________________________________________
There is a non-refundable adoption fee of $ ______. Is this acceptable to you?
___________
3. Home:
Do you ____ own or ____ rent where you live?
Type of dwelling (check one): ____ Single family home,____ townhouse,_____
apartment/condo, _____ other (specify)
If you rent, do you have permission from your landlord to keep a dog? _____________________
Landlord’s name and number. We will ask to see a copy of your lease._____________________
______________________________________________________________________________
Do you have a fenced yard? _____Yes _____No If yes, how high is it?
What type of fence is it? _________________________________________________________
If no, how will you provide exercise and safety outdoors for your dog?____________________
_____________________________________________________________________________
4. Family:
Children at home? _____________ Ages: _______________
Other Adults in Household? ________________________
5. Other Pets:
Please list all the pets you have owned in the past 10 years. Are they still
with you? If not, what happened to them? Have you ever given away, sold or
surrendered a pet? Under what circumstances?
______________________________________________________________________________
______________________________________________________________________________
Pet #1: Type ____________________ Still with you? ___ Yes _____ No
If yes, pet’s age ____ If no, what happened? __________________________________________
______________________________________________________________________________
Pet #2: Type ____________________ Still with you? ___ Yes _____ No
If yes, pet’s age _____ If no, what happened? _________________________________________
______________________________________________________________________________
Pet #3: Type ______________________ Still with you? _____ Yes ____ No
If yes, pet’s age ____ If no, what happened? __________________________________________
______________________________________________________________________________
Pet #4: Type ______________________ Still with you? _____ Yes ____ No
If yes, pet’s age ____ If no, what happened? __________________________________________
______________________________________________________________________________
Are you using a vet presently or have you used a vet in the last 12 months?
_________________
(We do collect vet references) If so, please provide name and phone number.
_____________________________________________________________________________
_____________________________________________________________________________
What kind of heartworm and flea preventative are your pets using? _______________________
6. Lifestyle:
How many hours are you away from home during an average work day? _________
hours. Do you or can you come home for lunch? ____ Yes, ____ No.
Is it required that you travel for work? ____ Yes, ____ No.
If yes, who will provide care for your pet while you are gone? ___________________________
_____________________________________________________________________________
All of the dogs we place are inside dogs. None are to live outdoors on a regular
basis. These dogs are NOT to be left outdoors most of the day. Is this acceptable
to you? _____ Yes, _____ No.
Exercise is important for a healthy and happy dog. What would you do to exercise
this dog?
______________________________________________________________________________
Where will the dog be kept during the day? __________________________________________
Where will the dog be kept at night/sleep? ___________________________________________
Where will the dog be kept when no one is at home? ___________________________________
What happens to the dog if you move? ______________________________________________
What do you see as normal pup/adult dog problems? ___________________________________
How would you encourage and reinforce appropriate behavior?___________________________
____________________________________________________________________________
How
would you discourage/prevent inappropriate behavior?_____________________________
______________________________________________________________________________
What circumstances, in your opinion, justify “getting rid of” a
pet?________________________ ____________________________________________________________________________________________________________________________________________________________
Have you or anyone in your household ever been convicted of animal cruelty,
neglect or abandonment? _________________________________________________________________
7. Health Issues:
Does anyone in the home have allergies? (details) ____________________________________________________________________________________________________________________________________________________________
Does anyone in the home have asthma? (details) ____________________________________________________________________________________________________________________________________________________________
Does anyone in the home have a disability or special needs we should know about?
(details) ____________________________________________________________________________________________________________________________________________________________
The following questions are asked so that the prospective adopter fully realizes what the cost and maintenance would be to have a dog in their home. Many prospective adopters are surprised at the cost of food, medical expenses, and grooming that are necessary to keep a dog in good health. Please answer these questions to the best of your ability.
Please estimate the amount you think it will cost yearly for the following:
Food $ ________
Grooming $ ________
Vet Care $ ________
Important information. All prospective owners must read and sign the following:
These dogs are in a rescue group because for one reason or another previous
owners no longer could or wished to care for them. The main purpose of The
Chance Foundation is to find responsible and reliable homes for all dogs placed
in their care. Adopting a dog is a very important decision and one that not
only affects your family, but the dog you decide to adopt.
Millions of dogs are euthanized each year because people do not seriously consider
the care and maintenance of animals. Time and attention are major factors that
need to be considered when taking a dog into your home. Medical expenses can
be costly. All the dogs in The Chance Foundation have been previously taken
to a vet for an examination. Basic shots are given, and spaying/neutering if
necessary. If there are extenuating medical factors involved, all will be noted
in the contract upon signing. It is the responsibility of the new owner to
provide additional and maintenance vaccinations if/as necessary, and any preventative
care required such as grooming, teeth cleaning, nail trimming, flea and heartworm
preventative.
In addition it is the responsibility of the owner to provide the necessary training/reinforcement to integrate their new dog into their home. If behavior problem arises, the owner agrees to contact The Chance Foundation to discuss further training. The owner may also hire a trainer or enter the dog into a training program that is not affiliated with The Chance Foundation, but must keep The Chance Foundation apprised of the animals progress.
By signing, you agree to have read and understood the above information. If you have any questions please feel free to contact us. We will be more than happy to help you.
Name of prospective adopter___________________________________ Date______________
Application reviewed by TCF member (signed) __________________________ Date________