Peace of Mind Dog Rescue · Adoption Questionnaire

Dog's Information

Dog's Name

*

Where did you hear this about this dog?

*

Other

*

Adopter's Information

Name

*

First Name

Last Name

Date of birth for person who will be primary caretaker for the dog

*

(mm/dd/yyyy)

Email

*

Verify Email

*

Email again

*

Please enter the same email address again

Verify Email

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Home Phone

*

Cell Phone

*

What is your preferred means of communication?

*

Home phone

Cell phone

Email

Text

Is the person filling out this questionnaire the person the dog will live with?

*

Yes

No

Please explain

*

How long have you lived at this address?

*

less than 6 months

6 months to 1 year

1 year to 2 years

3 years to 5 years

6 years or more

Type of housing

*

House

Apartment

Condo

Other

Other type of housing

*

Do you own or rent your home?

*

Own

Rent

Are you open to a POMDR representative coming to your home for a home safety inspection before adoption?

*

Yes

No

Please explain

*

Does your housing lease allow pets?

*

Yes

No

Name of lessor

Phone number of lessor

How many adults at this address?

*

Adults' ages

*

How many children at this address?

*

Children's ages

*

Have the children ever had a companion animal in the household before?

*

Yes

No

Will your adopted dog be regularly interacting with children other than the children living in the home?

*

Yes

No

Children's ages

*

Is anyone in your household allergic to dogs?

*

Yes

No

Current and Former Pets

Do you currently have any companion animals?

*

Yes

No

Descriptions, breeds and ages of all animals that reside with you now

*

How do your current pets generally do when meeting a new dog? Do you anticipate any issues with them getting along with a newly adopted dog?

*

Are all of your animals spayed or neutered?

*

Yes

No

Please explain (it is POMDR policy that all adopters have their cats and dogs altered)

*

Do your animals have current vaccinations?

*

Yes

No

Animals you've had in the past

Dog

Cat

Other

Other animals

*

When was the last time, and for how long?

*

If you no longer have the animal, what happened to them?

Have you ever surrendered one of your pets to a shelter?

*

Yes

No

Explain the circumstances

*

More About the Home for the Dog

Are you getting this dog as a gift for someone?

*

Yes

No

For whom?

Where will the dog live and sleep?

*

The dog will be

*

Strictly indoors

Strictly outdoors

Both indoors and outdoors

When and for how long would the dog be outdoors?

Will the dog have full access to your home?

*

Yes

No

Explain

What exercise would a dog get in your care? (Number of walks, length, on leash, off leash, backyard play, etc.)

*

Who will be the primary caretaker of the dog?

*

Who will care for the dog when you are away from home?

*

If your dog gets sick, can you afford vet bills?

*

Yes

No

How many hours per day will the dog be left alone?

*

How will your new dog spend a typical day?

*

Do you have a securely fenced yard?

*

Yes

No

Fence type and height

Do you have a dog door? (This is not required for adoption.)

*

Yes

No

Are there any smokers at your home?

*

Yes

No

Do they smoke indoors?

Yes

No

If you are adopting a senior dog (over 7 years old), have you cared for a senior dog before?

*

Yes

No

Not adopting a senior dog

Are you aware of the special care and expense senior dogs might require?

*

Yes

No

Do you have a plan in place for what would happen to your dog(s) if something happens to you?

*

Please let us know what particularly interested you in this dog, and provide any other comments about yourself and the home you are offering

Adoption Questionnaire Agreement

I confirm that all information supplied on this questionnaire is correct, and acknowledge that adopting a dog from POMDR is at my own risk. On behalf of myself, my heirs, personal representatives and executors, I hereby release, discharge, indemnify and hold harmless POMDR, its board of directors, officers, staff and all other persons and organizations in any way connected with POMDR from any and all claims, causes of action, or demands, of any nature or cause, including costs and attorney's fees incurred by POMDR in connection with the same, based on damages or injuries which may be incurred or sustained by me in any way connected with my adoption a dog from POMDR, including but not limited to animal bites, accidents, or injuries.

I understand that this confirmation and agreement does not guarantee I will be approved to adopt a POMDR dog. Approval is pending an interview, home safety check, and availability of dogs.

Photo Release

I understand that public relations is an important part of POMDR’s ability to raise funds for people like me in need of assistance . On behalf of myself, my heirs, personal representatives, and executors, I allow POMDR to use any photographs taken of me or my pet or submitted by me for use in public relations efforts including print materials, website, and social media. Also, all photographs that I submit to POMDR will remain the property of the photographer. POMDR will have the rights to use these photographs for marketing materials or in any other ways that POMDR sees fit.

I accept the Adoption Questionnaire Agreement

*

Yes

No

I accept the Photo Release

*

Yes

No

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