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? _____________ á 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? __________
Applicant ______________________________________ Date__________
Co-Applicant ___________________________________ Date__________
Page 5 – Adoption Application
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.
FOR RESCUE USE ONLY:
Reference calls made by: __________________________ Date ________
Home visit done by: ______________________________ Date _________ Comments:
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