Select CSRA Dog *
CSRA Dog
Which dog(s) would you like to adopt? *
If the dog(s) in which you are interested in is not available, will you consider adopting a different dog?
If the dog in which you are interested in is not available, will you consider adopting a different dog?
No Yes
Applicant's First Name *
Applicant's Last Name *
Street Address *
Apartment Number (if applicable)
City *
State *
Zip Code *
Home Phone Number
Please use the following format 248-555-1212
Cell Phone Number *
Email Address *
Please enter correctly as this is the main way we will contact you
Please list the names, ages & relationship of those who live in your home, including yourself. *
Is everyone in your household in agreement with your plan to adopt a dog? *
Yes
No
N/A
Does anyone in your household have allergies to dogs/cats? *
Yes
No
Possibly
N/A
What is your current employment status? *
Full-Time
Part-Time
Retired
Work from Home
Stay at Home Parent
Student
Unemployed
Other
What is the name and contact information for your current employer? *
How long have you worked for this employer? *
Do you own or rent your home? *
Own
Rent
Someone else owns the Home
Someone else rents the Home
If you rent, does your landlord and lease allow pets? *
Yes
No
Unsure
N/A
Manager/landlord name and phone number *
Pet deposit required? *
Yes
No
N/A
Size/breed limitation? *
Yes
No
N/A
If owned, do you have any pet restrictions? *
Yes
no
n/a
Please select your current residence type. *
House
Apartment
Condo
Townhouse
Mobile Home
Other
Do you have a completely fenced-in yard? If so, what kind of fence? *
Wood
Chain Link
Electric
Plastic
Iron
Other
Other (I do not have a fenced yard)
What is the fence height? *
How long have you lived at this address? *
Less than one month
1-2 months
3-6 months
6-9 months
9-12 months
1-2 years
3-5 years
6-10 years
10 + years
Do you own other pets at the current time? *
No Yes
If yes, please list their names, breeds, and ages. *
Veterinarian's name for pets in last 10 years *
List all of those used for the last 10 years. If you have never owned a pet please tell us where you would go, if possible. We can recommend if needed.
Veterinarian's Address, City, State, and Zip Code *
Address for vets used for the last 5 years for your pets. If none used, let us know if you need a recommendation for one.
Veterinarian's phone number *
Phone number for all vets used for your pets in the last 5 years.
Are all of your pets spayed/neutered/fixed? *
Yes
No
N/A
Are all of your pets current on their vaccinations? *
Yes
No
N/A
If your pets are not current on their vaccinations or fixed, why not? *
Do you provide heartworm preventive to your current/previous dogs? *
No Yes
How many pets have you owned in the last 5-10 years? *
If not with you now, what happened to your pets in the last 10 years? *
Who will be the primary caregiver for the dog? *
Please describe in detail the type of dog you are looking for. *
Please check the main reason you plan to adopt a dog: *
Companion
Family Pet
Child's Pet Guard Dog
Companion for another pet
Other
If you answered "other" above, please explain here:
On average, how many hours per day will your dog be left alone (including commute time)? *
Where will this dog stay when you are at work? *
Where will this dog stay when you are out running quick errands? *
Will this dog be predominantly living inside, outside, or both? *
Inside
Outside
Both
Are there times when the dog will be tied/chained up? *
Yes
No
N/A
If you do not have a fenced yard, how will you let the dog out? *
Describe a typical workday routine for this dog. *
Describe a typical routine for the days that you have off work. *
Do you have a pool? Is there a fence separating it from the rest of the yard? *
Where will the dog sleep? *
In bed with me
In bed with my child
In a dog / cat bed
In a kennel / crate
Wherever he or she likes
Outside
Other
How will you handle house training issues? *
How will you handle destructive behavior? *
Are you willing and able to exercise the dog on a regular basis? *
Yes
No
N/A
Will you keep the dog up-to-date on vaccinations and heartworm preventative? *
No Yes
If no, please explain:
Do children reside or visit your home? What ages? *
Describe the activity level in your home - slow, moderate, high energy. *
What kind of activities do you hope to do with your new dog? *
What will you do with the dog when you go on vacation? *
Leave with family/friend
Boarding
Pet sitter
Take with me/us
Other
What arrangements will you make for the care of your pets in case of an emergency? *
Leave with family/friend
Boarding
Pet Sitter
Take with me/us
Other
If you answered "other" above, please explain:
Please list an emergency contact that does not reside with you WITH CONTACT INFORMATION FOR THAT PERSON (phone or email). *
What would you do with your animal if you had to move? *
Take him / her with me
Give to family or friend
Return to shelter
Other
If you answered "other" above, please explain:
Are you willing to take responsibility for this animal for the next 10-20 years? *
No Yes
For what reason(s) would you consider returning/giving up your adopted dog? *
If for any reason you are unable to keep your dog, do you agree to notify Cocker Rescue and return the dog immediately? *
No Yes
Have you applied anywhere else for a dog? If so where? *
Why are you interested in adopting a cocker spaniel? *
How did you find out about us? *
Will you allow us to perform a pre-adoption home visit? *
No Yes
If located out of our area will you follow our checks: photos of home, come to us to meet the dog, return if needed? *
We will need photo's of home, yard & fencing along with you coming to us to meet the dog, if you adopt, dog is required to be transported only in cabin if flying and you are responsible to bring dog back into rescue if it doesn't work out.
No Yes
PLEASE READ CAREFULLY: As part of the adoption process, our organization does follow-ups on our placements. We will call and, if we deem necessary, do a home visit. You also understand that the adoption is not final for 30 days following placement. During that time, you are fostering our rescue. We reserve the right to void the adoption and pick up the dog.
People adopting cockers from Cocker Spaniel Rescue must understand that the organization has no background information on the animal's previous environment, behavioral problems (if any), and medical history. We can provide a current behavioral evaluation and medical history only.
Some diseases have long incubation periods, and a negative test is not a guarantee that the animal does not have a certain disease.
Introduction of a new animal into a home with existing animals carries a certain risk that must be assumed solely by the adopting party. Cocker Spaniel Rescue cannot be held liable for damages that may result from such an introduction. We are an organization operating as a community service with the intent to do only good and no harm.
Your signature on this agreement is your promise to have your Cocker protected from canine heartworm. In addition you promise to provide food, shelter, love, and all medical attention your pet requires. In the event that you are unable to keep your Cocker, you are required to inform Cocker Spaniel Rescue as soon as possible and to keep the animal until we can find a suitable home or return the animal to us. When you adopt an animal from Cocker Rescue, the cocker will have a collar and id tag. The tag is registered to this organization. You are strongly urged to have your own id tag made immediately. If the animal is picked up and traced to our organization because your tags are not on it, you may not get your pet back. We accept very few excuses for "loose" animals.
Electronic signature of Adoption Application. *
Date of signed Adoption Application *
What is your preferred type of communication email,phone or text? Please put "all" if all are ok *