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Golden Retriever Rescue of Central PA, Inc.  P. O. Box 397 Centre Hall, PA 16828 Telephone: 814-364-9744 E-mail: info@grrcp.org Web site: www.grrcp.org

Golden Retriever Rescue of Central Pennsylvania

Adoption Application

 Name of Applicant _________________________________Age ______

  Street Address_______________________________________________

  City ___________________________ State _____ Zip Code  _________

  Daytime Telephone _____________________________

  Evening Telephone _____________________________

  Best time to contact you _________________________________________

  E-mail (optional)_______________________________________________

  Name(s) of Co-Applicant(s) ______________________________________

  Age(s) _______________________________________________________

  Who will be Golden's primary care giver (if not applicant)?

  ____________________________________________________________

  Relationship: Spouse ______ Parent or Guardian __________

  Other (explain) ________________________________________________

  Will there be children living in the home with the Golden? _____________

  If so, how many? ____ Ages ______________________Gender_________

  Is there anyone in the home who is allergic to dogs? ___________________

Page 2 – Adoption Application

  Is the pet for (circle 1) an: Adult ___ Child  ___Elderly person ___

 Physically Challenged ____

  How did you learn about Golden Retriever Rescue of Central Pennsylvania?

  _____________________________________________________________

  Are you aware that a Golden Retriever is a large dog and may jump up and

 knock down someone?__________________________________________

  Do you live in a: House ____ Townhouse ____ Apartment ____

 Duplex ____ Mobile Home ___ Condominium ____

  Do you: Own _____ Rent ____ Do you have the landlord's permission to

 have a dog over 50 pounds? ________

  Do you have a fenced yard: Yes _____ No ____ Fence type and height

  _____________________________________________________________

  Where will Golden stay during the day? _____________________________

  At night? _____________________________________________________

  Is anyone home during the day? _________ Who? ____________________

  Will your Golden have the run of the house, be in blocked-off portions of

 the house, use a crate, be tied outside or live in the yard? Please be

 specific: _____________________________________________________________

  Will your dog be allowed on the furniture or the bed? __________________

  Is this your first dog? _______ First Golden? __________

  Are you aware that Goldens are active and shed year-around?___________

  Do you have any other pets? _____ Types and ages? ___________________

Page 3 – Adoption Application

  Have you ever sold, given away or surrendered a pet to a shelter? ________

  If so, please describe circumstances?_______________________________

  _____________________________________________________________

  _____________________________________________________________

Are you aware that the routine costs of maintaining a dog average $600 to

 $800 annually? ________________________________________________

  Name and telephone number of veterinarian? _________________________

______________________________________________________________

  May we contact him/her? _____________

  · I hereby authorize my veterinarian to release confidential   information about my pets and my pet care.

 Applicant's signature _______________________________ Date ________

 Co-Applicant's signature ____________________________ Date________

If you have applied to another rescue for adoption, please list the name:

  ______________________________________________________________

  Three personal references we may contact: Name and phone number of each

  _____________________________________________________________

  _____________________________________________________________

   ___________________________________________________________

  Age range interested in adopting: Any age _________ Adult____________

Senior (9+ years) _________

  Preference: Male _______ Female _________ No preference ___________

Page 4 – Adoption Application

  Would you consider a special needs dog, such as one that requires

 medication for a permanent but controllable medical condition? __________

 ·        In addition to your application please send us a detailed letter:

 n     About yourselves and those who will be living with and caring for the dog

n     Why you want to adopt a Golden Retriever. If you have any special requirements for a dog, please let us know so we can carefully match the dog to its “forever home.”

n     And describe in detail a typical week and weekend in the life of your dog. Please include any information about special activities in which your rescue dog would be included.

If, for any reason, the adopter should not be able to keep this dog, he/she is obligated to return the dog to GRRCP. _____________ Applicant’s initials

·        At the time of adoption, a non-refundable $250 adoption fee is required. Additionally, a $50 obedience deposit is also required at the time of adoption.  This money will be refunded to the adopter once proof of a completed obedience course (taken within 3 months of adoption) is presented to GRRCP. Obedience class is a bonding opportunity for the new owner and Golden Retriever, offers them the chance to work through any adjustment problems and may someday save your dog’s life.

·        Adopters are not selected on a first come basis. GRRCP has the right to refuse any applicant. We strive to choose the most compatible environment for our Golden Retriever rescue dogs.  Applicants must be over 21 years of age.

 Applicant ______________________________________ Date__________

 Co-Applicant ___________________________________ Date__________

Page 5 – Adoption Application

·        Please mail this application along with the non-refundable $25 application fee (made payable to Golden Retriever Rescue of Central Pennsylvania) to:

 Golden Retriever Rescue of Central Pennsylvania

 P. O. Box 397

 Centre Hall, PA 16828

  Applications without the $25 fee will not be processed until the fee is received.

·        Contact can be made by calling: (814) 364-9744 or by e-mail at info@grrcp.org

·        Thank you for your interest in giving a loving "forever home" to a needy Golden Retriever. Once the reference checks are complete, you will be contacted by a representative from GRRCP. The application process takes 2 to 3 weeks to complete before a home visit can be scheduled. Applying to adopt does not guarantee approval.

 FOR RESCUE USE ONLY:

Reference calls made by:  __________________________ Date ________

Home visit done by: ______________________________ Date _________

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