Adoption Application

1.  How did you hear of Illinois Cocker Rescue?

2.  Have you submitted an Adoption Application to any other rescue group(s)?  If so, please list.

3.  Name of Dog(s) You Wish to Adopt?         Breed

4.  Applicant Name Telephone

    Cell Phone

5.  Address

     City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Island Washington West Virginia Wisconsin Wyoming Zip Code

6.  Employer Work #

7.  Employer (spouse) Work #

8.  * REQUIRED * E-mail address

9.  Please list pets that currently reside in your home:

    Name: Breed: Gender:  Neutered:  Yes  No     Age:  Owned Since:
    Name: Breed: Gender:  Neutered:  Yes  No     Age:  Owned Since:
    Name: Breed: Gender:  Neutered:  Yes  No     Age:  Owned Since:
    Name: Breed: Gender:  Neutered:  Yes  No     Age:  Owned Since:
    Name: Breed: Gender:  Neutered:  Yes  No     Age:  Owned Since:

10.  Have you ever had to give up a pet?  If so, please explain.

11.  Why do you wish to adopt a dog?

12.  Would your pets accept a new dog? Yes  No

13.  If you currently have a pet, how often is it vaccinated for the following?

     a.  Rabies:                                         
     b.  Distempter (DHLPP or DA2PPL):   
     c.  Bordatella (Kennel Cough):             
     d.  Other (Explain): 

14.  If you currently have a dog, how often do you have him/her checked for heartworm (HW)? 

15.  What brand of HW preventative do you use for your dog? 

16.  How often do you give HW preventative? 

     12 months
     6 months
     3 months
     Not Applicable

17.  What brand of food do you currently feed your pets?

18.  Have you had pets in the past? Yes  No

19.  If so, please explain what happened to them.

20.  IMPORTANT:  If you have owned a pet within the past ten years, please fill out the following information.

    Dog's Name

    Veterinarian's Name/Clinic 

    Address

    City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Island Washington West Virginia Wisconsin Wyoming Zip Code

    Telephone Fax Email

    Pet's Name on Record with Veterinarian

ADOPTIVE FAMILY PERSONAL INFORMATION

21.  IMPORTANT.  Please list two personal references:

      Name  Relationship Day Tel. Evening Tel.

      Name  Relationship Day Tel. Evening Tel.

22.  Do you: Rent    Own
      House
      Apartment
      Condo

23.  IMPORTANT.  If renting, please provide landlord's name, address and telephone number. We require the landlord's written consent for your having a dog. Please include this consent when you return this application. The Adoption Application CANNOT be processed without written consent.

Landlord's name Telephone

Address

City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Island Washington West Virginia Wisconsin Wyoming Zip Code

24.  List ALL members of your household.

    Name: Age:
    Name: Age:
    Name: Age:
    Name: Age:
    Name: Age:
    Name: Age:

25.  Do you have much contact with grandchildren or other children? Yes  No

26.  What are the working hours of the adults in the house?

27.  Does anyone in the house have allergies? Yes  No

28.  Please describe the activity level of your home:

        Busy - visits by friends, meetings, children, parties at home
        Noisy - TV, stereo, machinery, tools, children playing, dogs barking
        Moderate - normal comings and goings
        Quiet - "homebodies," few guests

29.  In the absence of the primary caregiver, who cares for the dog?

30.  What will you do with the dog when you travel?

31.  Under which circumstances would you NOT keep the pet (check all that apply):

        a new job
        divorce
        move
        new baby
        illness
        other (please explain)

CARING FOR YOUR NEW DOG

32.  Why do you wish to adopt this breed?

33.  Have you ever owned this breed in the past? If so, please explain its good and bad characteristics:

34.  Do you plan to have your dog groomed on a regular basis? Yes  No

35.  IMPORTANT: Do you have a groomer? If so, please list name and phone number.

        Groomer's name Telephone

36.  Are you aware of the health problems common to this breed? Yes  No

37.  Are you willing to pay the veterinary costs of caring for your new dog? Yes  No

38.  Are you willing to continue your dog on a special diet/medications to maintain his/her health? Yes  No

39.  Are you willing to take the time to work with a dog on housebreaking issues, should the need arise? Yes  No

40.  If behavioral problems arise, what steps will you take to work on them?      

41.  Would you consider obedience training for your new dog? Yes  No

42.  What is your preference for gender? Female  Male  No Preference

43.  Please rank your color preference (Cockers Only: Buff, Black, Brown, Black/Tan, Parti, Doesn't Matter):

      First Choice:     
      Second Choice:
      Third Choice:    

44.  Please indicate age preference (under 12 months, 1-3 years, 3-6 years, 6+ years):

      First Choice:    
      Second Choice:
      Third Choice:    

45.  Where will the dog be kept during the day?

46.  Where will it sleep at night?

47.  Where will it be kept when left alone?

48.  Where and how often will the dog be exercised?

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

50. If you are gone for longer than 5 hours during the day, please explain what arrangements you have made to have your dog walked.

51.  Please list name and phone number of dog walker.

52.  Do you have a securely fenced yard? Yes  No

53.  If so, how high is the fence?

54.  If not, are you willing to fence, install a pen or run, or leash walk at all times? 

        Yes (please specify)
        No

FINALIZING THE ADOPTION APPLICATION

I have read the above information carefully and have answered the application honestly. I understand that omission of information and/or failure to answer all questions can result in this application being declined. If an omission or untruth is discovered after an adoption occurs, I understand and accept that Illinois Cocker Rescue has the right to annul the adoption and reclaim the dog. Yes  No

I give Illinois Cocker Rescue permission to fully investigate the information provided on this application as well as to contact all references noted herein. If the application passes the review, I agree to a pre-adoption home and yard visit on a mutually agreed date by an Illinois Cocker Rescue representative before an adoption decision is made. Yes  No

I understand that the rescued dogs at Illinois Cocker Rescue were restored to health by being fed a natural diet. If I adopt a dog from Illinois Cocker Rescue, I agree to continue feeding the dog a raw diet--whether homemade or frozen--or at a minimum, to feed a NATURAL dog food (see Dog Feeding) supplemented with fresh raw foods. Yes  No

I understand that I will be put on a list of prospective adopters who are desirous of adopting this rescued dog. The family that is considered the best match for a given dog will be given first priority to adopt this dog. Yes  No

I agree to return the adopted dog to Illinois Cocker Rescue in the event I can no longer care for him/her. I understand that the adoption fee is non-refundable. Yes  No

I agree to pay an adoption donation to help defray the medical expenses and other costs of rescue. Yes  No

The adoption donation begins at $250 and varies according to age, breed, and veterinary work required to get them healthy.  At a minimum, the veterinary work includes spay/neuter, dentals (if required), microchip, heartworm test, as well as a 3 Yr Rabies vaccination.