Adoption Application

Save Just One

RR 3 Box 1502 ~ Jonesville, Virginia ~ 24263 ~

Adoption Application

Thank you for your interest in adopting a companion pet from Save Just One. The purpose of this application is to match the dog with the family, hopefully where the dog will become a family member of a loving and caring home. Adopting a rescued animal is a responsibility which places an emotional, physical, and financial burden on the adopting family. With the dog's best interest at heart, we want to be assured that you and your family are prepared to deal with those issues. Upon receiving your application you will be contacted by a representative of Save Just One for a telephone interview. Other steps include verification of the information provided and checking references which will include, if applicable, contacting the veterinarian who provides care of any other pets in the home, or pets you have had previously. A home visit by a representative of Save Just One is required, and all family members must be present. After these steps are completed, you will be contacted regarding the status of your application. If approved, signing of the Adoption Agreement finalizes the adoption.

Name of applicant:_____________________________________________________

Address:______________________________________________________________________________________

City: ______________________________ State: ______________ Zip code: ______________

Home phone: ______________________ E-mail: ____________________________________

Applicant's employer: _________________________ Position: ________________ Phone: _________________

The dog or type of dog you are interested in adopting: ____________________________________________________

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Veterinarian's name: ____________________________ Veterinarian's Phone number: _____________________ __________________________

Number of children in your home: ____ Ages: _____________ Do they live with you full time? Y/N _______

Number of adults living in your home: ____ Is anyone home during the day? Y/N ___ Who? ______________

Who will be responsible for caring for the dog? ______________________________________________________

Other pets presently in the home - please list, including type of animal/breed, age, how long they have been with you, gender, whether neutered/spayed, vaccinated, are they on heartworm preventative?

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Location of your home (check one): Suburban _____ Urban ____ Rural ____

Type of home: House ___ Apartment ___ Townhouse ___ Condominium ___ Other ___

Do you:   Own ___   Rent ___ (If you rent, proof that you are allowed to have dogs must be provided.)

                                Name of landlord and phone number: _________________________________________________

Level of activity in your home: Active ___ Moderate ___ Quiet ___

Do you have a fenced in yard? Y/N ___ If yes, what type and height of fence do you have? ____________________

If fenced, how many gates? ____ How are the gates secured? ____________________________________________

Why do you want to adopt a dog? _________________________________________________________________ ______________________________________________________________________________________________
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Will the dog be kept: Indoors ___ Outdoors ___ Equally indoors and outdoors ___ Tied outside ___

How long will be dog be left alone during the day? ____________________________________________________

Do you have a: Dog house ___ Outdoor kennel ___ Dog run ___ Other (describe) _________________________

When the dog is home alone it will be: Allowed free movement throughout the house ___ Confined to one room ___

Crate trained ___ Left Outside ___ Left in the garage or other bldg. ___________

How much do you think the cost of properly caring for this dog will cost annually (including food, vet care, licensing, grooming, and any other expenses)? ______________

This dog could depend upon you for another ___ years. Are you prepared to make that commitment? Y/N ___

Have you ever given up a dog before? If so, why? _____________________________________________________

What type of behavior problems would make you decide to return a dog? Housebreaking issues ___ Chewing ___

Shedding ___ Digging ___ Excessive barking ___ Not compatible with other animals ___

Other (describe) ____________________________________________________________________________

Most rescued dogs have been abandoned, abused, neglected, or traumatized and may have behavioral and/or emotional issues. They may have medical conditions which require medicines or extra veterinary care. Are you and your family prepared to deal with these potential issues? If it is a puppy that requires training and constant attention, are you willing to provide that? Would you be willing to attend obedience classes? Would you crate train? Most of our rescued dogs spend enough time in their foster homes for the foster care person to be able to evaluate any behavioral and/or emotional problems with the dog, and you will be advised of any observances made. Please respond to this in your own words.

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What will you do with the dog when you are on vacation? _________________________________________________

What if an emergency arises and you have to go out of town unexpectedly? ____________________________________

What will you do with the dog if you move? ____________________________________________________________

Which of these circumstances would make you decide to return the dog? Move ___ New Baby ___ Divorce ___

Personal Illness ___ High Cost of the Animal's Care ___ Other (describe) _______________________________

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Please list previously owned animals and describe what happened to them: _____________________________________________________________________________________________
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References: (no family members - should include a neighbor and a vet)

1. ______________________________________ Phone (H) _________________ Phone (W) ________________

2. ______________________________________ Phone (H) _________________ Phone (W) ________________

3. ______________________________________ Phone (H) _________________ Phone (W) ________________

Because we care about the animals adopted from our rescue group, we periodically contact the adopter for an update on how the animal is adjusting to its new home. If you adopt a pet from Save Just One, will you consent to occassional contact to inquire if the dog is doing well in your home? Y/N ___

Adoption Fee: To cover expenses of spay/neuter, vaccinations, or other veterinary costs, we ask that an adoption fee be made payable to Save Just One. (This varies, but ranges from $75 to $200.) The adoption fee for this dog is ______.

I hereby acknowledge that I have read this application completely, comprehend it fully, and I understand that applying does not ensure approval for adoption. Furthermore, I understand that untruthful answers or failure to comply with the requirements of this application or the adoption agreement can result in the forfeiture of any animal adopted by me from Save Just One.

Signed: ______________________________________ Date: _______________________

Saving the life of a rescued dog is worth the extra effort it may require from the family. They can become the most outstanding family members you could hope for - rewarding you with unconditional love and devotion. Most of them only need someone to love and to be loved!

We thank you for those who cannot speak for themselves (except for the shine in their eyes and a wagging tail).

"Save Just One"
RR 3 Box 1502
Jonesville, Virginia 24263
Phone: 276-346-4257