Adoption Contract - Calhoun County, Iowa
This questionnaire has been designed to help us determine whether an adoption is in the best interests of both pet and adopter. Please answer all questions or put NA if they do not apply to you.
QUESTIONNAIRE FOR DOG ADOPTION
SECTION I
Date ________________
LAST NAME _____________ FIRST __________ MIDDLE ________PHONE H)____________(CELL)___________________
ADDRESS____________________ CITY________________ STATE_______ZIP _________
NAME OF PET Y0U ARE APPLYING FOR _______________________ IF THIS DOG IS IN THE NCCF TRAINING PROGRAM, ARE YOU A FAMILY MEMBER OR RELATIVE/FRIEND OF AN INMATE? ______________ NAME ______________________
EMAIL _________________________________________
ARE YOU: EMPLOYED________ STUDENT______ RETIRED______ OTHER_______
TYPE OF RESIDENCE: HOUSE_______ APARTMENT_______ MOBILE HOME______ FARM _____
DO YOU OWN _______ RENT_______ HOW LONG HAVE YOU BEEN AT THE RESIDENCE? _______
IF YOU RENT, DOES LANDLORD ALLOW PETS? YES_____ NO_____
LANDLORD'S NAME________________________________________PHONE____________
(WILL BE VERIFIED BY REPRESENTATIVE)
DO YOU PLAN T0 MOVE IN THE NEAR FUTURE? YES_____ NO_____
ARE OTHER FAMILY MEMBERS AWARE YOU PLAN TO ADOPT A PET? YES____ NO____
SECTION II
1. REASON FOR ADOPTION: COMPANIONSHIP ____ HUNTING _____ 4-H ____
WATCH/GUARD ______ GIFT ____ PET COMPANION ____
(IF GIFT, GIVE NAME OF AND RELATIONSHIP TO RECIPIENT)
2. NUMBER OF ADULTS IN HOUSEHOLD _____ NUMBER OF CHILDREN AT HOME ______
AGES OF CHILDREN ________________
3. DO YOU HAVE PETS NOW? YES ___NO ___ HOW MANY--DOGS___ CATS___ OTHER___
WHAT BREED, SIZE, AND AGE ARE OTHER DOGS IN THE HOME?
4. IF YOU HAVE PETS, HOW MANY ARE SPAYED OR NEUTERED? __________
CURRENT ON SHOTS? _________
5. DO YOU HAVE A FENCED IN YARD? _________________ WHAT TYPE OF FENCING AND SIZE OF ENCLOSURE?
6. WHAT KINDS OF PETS HAVE YOU HAD IN THE PAST?
7. WHAT HAPPENED TO YOUR LAST PET?_____________________________________________
8. HAVE YOU EVER LOST A PET DUE TO: POISONED_____ HIT BY CAR____ DISEASE_____
STRAYED/STOLEN_____ OLD AGE______
9. HAVE YOU EVER HAD TO GIVE UP A PET? YES____ NO____ IF YES, WHY?
10. IF YOU MOVE IN THE FUTURE, WILL YOU BE ABLE TO KEEP YOUR PET(S)? IF NO, WE WILL WORK WITH YOU TO TAKE IT BACK OR FIND ANOTHER SUITABLE HOME.
YES_____ NO_____
11. ARE YOU AWARE OF AND PREPARED TO MEET THE FIRST YEAR'S COST OF REGULAR PREVENTIVE VETERINARY CARE ($100 TO $200 PER YEAR) AND QUALITY FOOD, SUPPLIES, TRAINING YES _____ NO _____
12.IS ANYONE IN YOUR FAMILY ALLERGIC TO ANIMALS? YES _____ NO _____
13. WHO IS YOUR PRESENT VET, WHAT IS THEIR CLINICS PHONE NUBMER?
14. WHAT TIMES WOULD BE BEST FOR REPRESENTATIVE TO CALL OR VISIT?
15. HAVE YOU EVER BEEN REFUSED BY AN HUMANE ORGANIZATION WHEN APPLING TO ADOPT AN ANIMAL?
YES _____ NO _____ , IF YES, WHEN ____________. WHICH ORGANIZATION? _______________ AND WHAT WAS THEIR REASON FOR DOING SO ________________________________ .
SECTION III
1. WILL YOUR PET LIVE INDOORS ___________ OUTDOORS ___________
WHEN OUTSIDE, HOW WILL IT BE CONFINED?______________________________________
WHAT KIND OF SHELTER DO YOU HAVE?__________________________________________
HOW DO YOU PLAN TO HOUSETRAIN?_____________________________________________
2. DO YOU FEEL WILLING AND ABLE TO WORK WITH YOUR PET AND CORRECT PROBLEM BEHAVIOR IF IT SHOULD DEVELOP (BARKING, FENCE JUMPING, DIGGING, CHEWING, ETC.)?
YES _______ NO _______
WHAT ARE YOUR IDEAS FOR DEALING WITH SUCH BEHAVIOR? (NOT ALL PROBLEM BEHAVIOR CAN BE CORRECTED, BUT MOST CAN BE WITH PATIENCE, PERSEVERANCE, AND EXPERT HELP IF NEEDED)
3. WHO WILL BE RESPONSIBLE FOR YOUR NEW PET'S CARE?__________________________
4. ABOUT HOW MANY HOURS A DAY WILL YOUR PET BE ALONE?_____ HOW MANY DAYS A WEEK____
WHERE WILL IT BE KEPT WHEN LEFT ALONE? (CRATE, LOOSE INSIDE, KENNEL ETC.)
5. WHERE DO YOU WANT THE DOG TO SLEEP? CRATE, LOOSE, BED?
6. WHAT TYPE OF I.D. DO YOU PLAN TO HAVE FOR YOUR PET?___________________________ ALL ANIMALS ADOPTED WILL HAVE BEEN MICROCHIPPED. ARE YOU WILLING TO MAINTAIN THE REGISTRATION TO KEEP IT UP TO DATE? THIS MAY INVOLVE A SMALL FEE FROM THE COMPANY.
YES_____ NO_____
7. WHAT BRAND OF FOOD DO YOU PLAN TO FEED? _____________________________________ DO YOU NEED INFORMATION ON CHOOSING A QUALITY FOOD?
8. ADOPTION POLICY AND IOWA LAW (FOR PETS FROM POUNDS AND SHELTERS) REQUIRE THAT ADOPTED ANIMALS BE SPAYED OR NEUTERED. DO YOU AGREE WITH THIS?
YES______ NO_______
9. ARE YOU PREPARED TO GIVE YOUR NEW PET PLENTY OF TIME (AT LEAST TWO WEEKS IN MOST CASES -- POSSIBLY MORE IF YOU HAVE OTHER PETS) TO ADJUST TO ITS NEW HOME?
YES _____ NO _____
10. WOULD YOU CONSIDER ADOPTING TWO DOGS FOR COMPANIONSHIP -- ESPECIALLY IF THERE IS OFTEN NO ONE HOME? YES ______ NO ______
I CERTIFY THAT THE INFORMATION I HAVE GIVEN IS TRUE AND AUTHORIZE INVESTIGATION OF ALL STATEMENTS MADE ABOVE. I UNDERSTAND THAT THE POUND HAS THE RIGHT TO REFUSE ANY REQUEST FOR ADOPTION. IN ADDITION I GIVE PERMISSION TO THE POUND AND THEIR ASSOCIATE FACILITIES TO SHARE INFORMATION ABOUT ME THAT MAY BE OBTAINED DURING INTERVIEWS, REFERENCES CHECKS AND HOME VISITS WITH OTHER HUMANE ORGANIZATIONS.
_______________________________________________ ______________________________
ADOPTER DATE
PLEASE RETURN TO CALHOUN COUNTY CANINE SHELTER, 501 COURT STREET, ROCKWELL CITY, IA 50579
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