A Program of the Central Pennsylvania Animal Alliance
	Application to Adopt Sarge Pet's Name:  Applicant's Contact Information Co-Applicant's Contact Information (Optional) First Name: First Name: Last Name: Last Name: Occupation: Occupation: Age: Age: Address: City: DC DE MD PA VA    Zipcode: Home Phone: Work Phone: (optional) Cell Phone: (optional) Email Address: Please list any other adults living in the home and their relationship to the applicant: 1. Type of Residence: --Select Type-- Single Family Home Townhouse Apartment Condominium Mobile Home Duplex Live with parents Other If other is selected, please explain: 2. Do you own or rent? Own      Rent A copy of your lease or a notarized statement from your landlord confirming a large dog is permitted is required for approval. 3. How did you hear about GoldHeart? --Select One-- From the World Wide Web From a Friend Your Veterinarian Newspaper Other If other is selected, please explain: 4. Have you applied to another rescue? Yes      No If yes, which rescue? How long ago? Were you approved to adopt? Yes      No If you were not approved, provide the reason(s) you were not approved: A successful adoption depends on selecting the right Golden for your household and a good understanding of the dog's needs and care requirements. Please help us with this process by answering the following questions fully and completely. An area is provided at the bottom of this form for you to convey to us any additional necessary information you can't fit in the space provided on the form. 5. Why do you want to adopt a Golden Retriever? 6. What will the dog be used for? --Select One-- Companionship Hunting Guard Dog Protection Other If other was selected, please explain: 7. Please list all pets currently residing in your home. Please provide information on their temperament and any special needs. If none of your current pets are dogs, have you owned a dog as an adult? Yes      No As an adult, have you ever owned a golden? Yes      No 8. What age Golden do you prefer? --Select One-- Under 1 year 1 to 3 years 4 to 6 years Over 6 years No Preference 9. Would you prefer a male or female? Male      Female      No Preference 10. Would you consider adopting a special needs dog that required medication for a permanent but controlled condition? Yes      No      Possibly      Not at this time 11. On a scale of 1 to 5 (with 5 being the most energetic), what activity level would best fit you family situation? 1      2      3      4      5 12. The annual cost of vet care, food, and supplies for a healthy dog can easily cost $1,000 a year. Does this fit within your family budget? Yes      No 13. Do you have a completely fenced yard? Yes      No If yes, what type of fence? --Select One-- Chain Link Invisible Fence Wood Split Rail Split Rail with Wire Mesh Other Fence height? --Select One-- 3 feet 4 feet 5 feet> 6 feet If you do not have a fence, would you consider installing:      A conventional fence? Yes      No      Possibly      An invisible fence? Yes      No      Possibly 14. How will you exercise your dog? Where will you exercise your dog? How often will you exercise your dog? Who will supervise the dog during outdoor activities? Will the dog be allowed off leash? 15. Would there be any circumstances where the Golden would be tied or left outside for exercise or potty breaks? Yes      No If yes, under what circumstances? 16. Do you have any of the following?      A dog door? Yes      No      An outside Kennel? Yes      No      A dog run? Yes      No      Tieout? Yes      No      An overhead Cable? Yes      No      Dog House Yes      No If you have any of the items in question 16, please provide information on how they would be used. 17. How many children are in the home? Their ages? Do they have experience with large dogs? Yes      No 18. What will be the children's involvement in caring for the new Golden? 19. Do you provide child care in your home? Yes      No How often, and how many children? 20. Where will the dog stay when no one is at home? Be specific. 21. Where will the dog sleep at night? Be Specific. 22. Is someone home during the day? Yes      No If yes, who in your household? 23. Are your other pets up to date on vaccinations and Heartworm preventative? Yes      No If not, please explain why? 24. Describe a typical day in your household. 25. Who will be the primary care giver(s)? Who will be the secondary care giver(s)? 26. Who will care for your Golden while you are on vacation? 27. If you move, what will happen to the Golden? 28. Are you prepared and willing to be responsible for the care of the Golden for the next 10 or more years of their life? Yes      No 29. Does anyone in the household have allergies? Yes      No Have asthma? Yes      No If yes to either, how is it controlled? 30. Have you ever attended obedience classes with a former or current dog? Yes      No Attended agility classes? Yes      No 31. Would you be willing to attend obedience classes with your new dog? Yes      No If you are unwilling to attend obedience classes with a new dog, please provide your reasons. 32. Have you ever participated in K9 sports with a dog? Yes      No If yes which one? 33. Have you ever crated a dog? Yes      No If yes, when?   34. Would be willing to crate the new dog? Yes      No 35. If you prefer not to crate a dog, please explain why. 36. Have you ever had a dog stolen, lost, or die prematurely? Yes      No If yes, please explain the circumstances: 37. Have you ever sold or given away a pet? Yes      No If yes, please explain the circumstances:   38. Have you ever surrendered a dog to a shelter? Yes      No If yes, please explain the circumstances:   39. Provide the names, and telephone numbers of at least two non-family references. 40. Provide the name, address and telephone number of your current veterinarian. If you do not currently have a veterinarian, provide contact information for the veterinarian you intend to use in the future and identify them as a new one. 41. If you have additional information you would like to include, please enter it in the box below. 42. Do you affirm that all of the information provided herein is accurate and complete? Yes      No
	Hounds of Prison Education A Program of the Central Pennsylvania Animal Alliance