Adoption Application Please complete all required fields! Please fill out the following application completely. The adoption process is designed to match our dogs with the right home. Typically our dogs require the safety of a fenced in area. There are exceptions to this depending on the dog and your overall environment/lifestyle. Please contact us with any questions. We also require applicants to provide us with photos of your home (outside, driveway, nearest road & inside common areas), and yard (proof of fencing). All required fields are marked with an (*). Applicant Information What dog are you applying for?(*) Please enter the name of the dog you would like to adopt. Name(*) Please enter your name [first name last name]. Street Address(*) Please enter your street address. City(*) Please enter the name of the city where you live. State(*) Please enter the state where you live. ZipCode(*) Please enter your zip code. Home Phone Please enter your home phone number. Leave blank if you do not have one. Cell Number(*) Please enter your cell/mobile phone number in the format nnn-nnn-nnnn EMail Address(*) Please enter your email address. Occupation(*) Please enter your occupation. How did you hear about PWD?(*) Please tell us how you heard about Pets With Disabilities. Next > Home and Life Information How many Children are in the house?(*) How many children live in your home. Enter 0 if there are no children. What are the ages of the children? What are the ages of these children? Do you have an active household with other children visiting frequently?(*) Yes No Please let us know if there are other children that visit your home. How many adults currently live in your home and what is their relationship to you?(*) Please let us know about the other adults that reside with you, If there are none, please enter "none". How many dogs have you had in the past 5 years?(*) Please let us know how many dogs you have had in the past 5 years. Do you still have these dogs?(*) YesNoNo previous dogs Please respond. If no, please give the reason they are no longer with you. Invalid Input Are there any cats or other small animals (i.e. guinea pig, hamster, rabbit, or bird) or exotics in your home? Please elaborate.(*) Please respond on how many animals do you have in your house Have you had a rescue dog before?(*) Yes No Please respond. If yes, from where? Invalid Input Why have you decided to adopt a dog with a disability?(*) Please let us know why you would like to adopt a disabled dog. Please describe a day in the life of the dog in your home(*) Please let us know about a day in your dog's life. < PrevNext > Animal Information Please fill out the information below about the current pets(s) in your home. Animal 1 Animal Name Invalid Input Animal Breed Invalid Input Animal Sex and Age Invalid Input Animal Spayed or Neutered? Yes No Invalid Input Up to date on vaccines? Yes No Invalid Input Good with other dogs? Yes No Invalid Input < PrevNext > Animal Information (continued) Please fill out the information below about the current pets(s) in your home. Animal 2 Animal Name Invalid Input Animal Breed Invalid Input Animal Sex and Age Invalid Input Animal Spayed or Neutered? Yes No Invalid Input Up to date on vaccines? Yes No Invalid Input Good with other dogs? Yes No Invalid Input < PrevNext > Animal Information (continued) Please fill out the information below about the current pets(s) in your home. Animal 3 Animal Name Invalid Input Animal Breed Invalid Input Animal Sex and Age Invalid Input Animal Spayed or Neutered? Yes No Invalid Input Up to date on vaccines? Yes No Invalid Input Good with other dogs? Yes No Invalid Input < PrevNext > Animal Information (continued) Please fill out the information below about the current pets(s) in your home. Animal 4 Animal Name Invalid Input Animal Breed Invalid Input Animal Sex and Age Invalid Input Animal Spayed or Neutered? Yes No Invalid Input Up to date on vaccines? Yes No Invalid Input Good with other dogs? Yes No Invalid Input < PrevNext > Home Information Do you have a fenced yard?(*) Yes No Invalid Input If yes, what type of fence? Invalid Input If yes, height of fence? Invalid Input If yes, approximate size of fenced area? Invalid Input Do you rent or own your home?(*) Own Rent Invalid Input If rented, can you provide written permission form your landlord to have pets? Yes No Invalid Input Is your neighborhood?(*) Urban Surburban Farm/Rural Invalid Input Do you live in a(*) Single Family Home (detached) Townhouse Apartment Condo Mobile Home Invalid Input How many levels does your home have?(*) 1 level 1 level (with basement) Multi-levels (2 or more) Multi-levels (with basement) Invalid Input How many steps are there at the entrance to your home?(*) Invalid Input How many steps are there at the entrance to fenced-in area?(*) Invalid Input Photos Please upload a photo of your home and yard. JPG/JPEG format only and less that 1 MB each. Home Photo Invalid Input Yard Photo Invalid Input < PrevNext > The Dog's Life Will the dog?(*) Have free run inside? Be crated? Allowed to run loose outside if yard is fenced? Tied out at any time? Invalid Input How do you intend to exercise this dog?(*) Invalid Input How many hours will the dog be left alone?(*) Invalid Input Where will the dog spend the day?(*) Invalid Input Where will the dog spend the night?(*) Invalid Input Do you have any prior experience with a dog with a disability? If yes, please elaborate.(*) Invalid Input You may need to assist your new dog as they adapt to their new surrondings. This may include re-arranging furnitore and being patient as they learn to navigate their new life. What are your expectations for the first 3 weeks for your new dog?(*) Invalid Input What behaviors would be intolerable in your home such as bathroom habits, barking, chewing, getting along with other dogs, getting along with people.? Please elaborate on these behaviors..(*) Invalid Input < PrevNext > Personal References We require two references. One should be a neighbor and one should be a friend. Reference 1 - Neighbor Reference Name(*) Please enter the name of your neighbor reference. Phone Number(*) Please enter the phone number of your neighbor reference. Format should be xxx-xxx-xxxx EMail(*) Please enter a valid email address for your neighbor reference. Reference 2 - Friend Reference Name(*) Please enter the name of your friend reference. Phone Number(*) Please enter the phone number of your friend reference. Format should be xxx-xxx-xxxx EMail(*) Please enter a valid email address for your friend reference. Veterinarian References We require information on your veterinarian and animal hospital Do you have a veterinarian?(*) Yes No You must respond yes or no to this question. Veterinarian Name Invalid Input Veterinarian Phone Number Invalid Input Veterinarian Hospital Invalid Input < PrevNext > Adopter's Statement of Commitment All of the above information I have given is true and complete. I also agree that this dog will reside in my home. I will provide the dog with adequate food, water, shelter, training, affection and medical care and the dog will not be tied out or on a run. All information provided by PWD about the dog is our best representation of our interactions with him/her IN our environment. By typing my name below, dating, and submitting this application, I agree to the Adopter's Statement of Committment and give Pets With Disabilities permission to contact our Veterinarian. Applicant Name/Signature(*) You must type your name in order to agree to the application statements. Date of Agreement(*) You must specify the date of your agreeing to teh terms of this application. Rescue Statement of Commitment We reserve the right to refuse an applicant for any reason if we feel the needs of the dog will not be properly met or the adoption is not in the best interest of the dog. The adoption fee is $400.00. Thank you for contacting us. You will be contacted shortly in response to your application. < PrevSubmit Application
