ADOPTION QUESTIONNAIRE

Dog's Name:___________________________________________________________________________         Age: ________

Color / distinguishing marks ______________________________________________________________________________

The following are questions to help place the right pet with the right family and to identify you.

1.              Personal information

                Name of potential adopter ___________________________________________________________________________

                Driver's license number _____________________________________________________________________________

                Home address where the dog will reside: _______________________________________________________________

                _________________________________________________________________________________________________

                Home telephone number: (       ) __________________           E-mail address: ____________________________________

                Your employer: _____________________________________________           Business phone: (        ) ________________

                Spouse's employer: _________________________________________           Business phone: (        ) ________________

2.              Why have you chosen a cocker spaniel to adopt? ________________________________________________________________________________

         This specific dog? _________________________________________________________________________________

                How long has it taken you to decide to adopt a cocker spaniel? ________________________________________________________________________________

                There is a non-refundable adoption fee of $________.  Is this acceptable to you?  ____ Yes  ____ No.

3.      Home

Do you _____ own or _____ rent where you live?  Type of dwelling (check one): _____ single family home

_____ townhouse  _____ apartment/condo  _____ other (specify)____________________________________________

If you rent, do you have the approval to keep a dog from your Landlord? 

Landlord's name and telephone number ________________________________________________________________

_______________________________________________________________ We will ask to see a        copy of your lease.

        Do you have a fenced yard?  If so, how high is your fence? __________ft.

What kind of fence is it? _____________________________________________________________________________

 4.     Family

Do you have children? _____Yes. _____ No.  If so, what are their ages? _______________________________________

Are there other adults in the home not listed above? _______________________________________________________

5.     Other Pets

Please list all the pets you have owned in the past 10 years. Are they still with you?

If not, what happened to them? Have you ever given away, sold or surrendered at pet?
Under what circumstances? __________________________________________________________________________

Pet #1: Type _______________________________________________________ Still with you? _____ Yes  _____ No

If yes, pet's age _______ If no, what happened? __________________________________________________________

Pet #2: Type ________________________________________________________ Still with you? _____ Yes  _____ No

If yes, pet's age _______ If no, what happened? __________________________________________________________

Pet #3: Type ________________________________________________________ Still with you? _____ Yes  _____ No

If yes, pet's age _______ If no, what happened? __________________________________________________________

Pet #4: Type ________________________________________________________ Still with you? _____ Yes  _____ No

If yes, pet's age _______ If no, what happened? __________________________________________________________

        Are you using a vet presently or have you used a vet in the last 12 months? (We collect vet references.) If so, please provide name, address, and phone #. ____________________________________________________________________________________________

_________________________________________________________________________________________________

6.     Lifestyle

How many hours are you away from home during an average work day? ___________ hours.

Do you or can you come home for lunch? _____ Yes _____ No

        Is it required that you travel for work? ______Yes. ______ No. 

If yes, who will provide care for your pet while you are gone? ________________________________________________

        All Cockers placed are inside dogs. None are to live outdoors on a regular basis. These dogs are NOT to be left out-in-the owners' absence.  Is this acceptable to you? ______ Yes. _____ No.

        Exercise is important for a healthy and happy dog. What would you do to exercise the Cocker? ________________________________________________________________________________________________

_________________________________________________________________________________________________

         Where will the dog be kept during the day? _______________________________________________________________________________________________

         Where will the dog be kept at night/sleep? _______________________________________________________________________________________________

         Where will the dog be kept when no one is at home? ________________________________________________________________________________________________

        What happens to the dog if you move? _______________________________________________________________________________________________

         What circumstances, in your opinion, justify "getting rid of" a pet? ______________________________________________________________________________________________

         _________________________________________________________________________________________________

7.     Health issues:

        Does anyone in the home have allergies? (details) ________________________________________________________________________________________________

        Does anyone in the home have asthma? (details) ________________________________________________________________________________________________

Does anyone in the have a disability or special needs that we should know about? (details) _________________________________________________________________________________________

_________________________________________________________________________________________________

The following questions are asked so that the prospective adopter fully realizes what the cost and maintenance would be to have a cocker spaniel in their home. Many prospective adopters are surprised at the cost of food, medical expenses, and grooming that are necessary to keep a cocker spaniel in good health. Please answer these questions to the best of your ability.

8.     Please estimate the amount you think it will cost yearly for the following:

Food (Premium food. Many cockers have both skin and food allergies due to poor quality food)

 $_____________.

Grooming (This should be done every 6-8 weeks, but can go as long as 3 months if necessary. Any longer and you will have a major problem.)                   

          $_____________.

Vet Care (This includes shots, heartworm and flea preventive.

It also includes maintenance of ears, teeth etc for your dog).                                                                                            $_____________.

 9.       Other concerns/thoughts:

          Would you consider a special needs dog, such as one that requires daily medication or one that is deaf?

Would you consider adopting a dog with a disability?

Would you consider adopting more than one dog?

         Would you consider fostering?

       Why do you feel a rescue dog is right for you/your family?

       Why do you feel your home is right for a rescue dog?

       How did you hear about us?

IMPORTANT INFORMATION:

These cockers are in a rescue group because for one reason or another previous owners no longer wanted to take care of them. The main purpose of this organization is to find responsible and reliable homes for all cockers placed in their care. These animals are thinking and feeling creatures, but not able to provide the care they need. Adopting a dog is a very important decision and one that affects not only you and your family, but the dog you decide to adopt. Millions of dogs are euthanized every year because people do not take seriously the maintenance and care of animals. The care and maintenance of a cocker spaniel can be costly. Time and attention are major factors that also need to be considered. All cockers in the program have been taken to the vet for an examination. Basic shots are given, and spaying/neutering if necessary. All cockers are in good health upon adoption. If there are extenuating medical factors involved all are noted on the contract at signing. It is the responsibility of the new owner to provide additional shots as necessary, and any preventative care required such as teeth cleaning, and heartworm and flea preventative.

                                                   I AGREE_________         I DISAGREE__________

The adoption fee is used to provide medical care, food, shelter, and advertising for the cockers. THE FEE IS NON-REFUNDABLE. The fee must be paid upon signing the contract. If, for any reason, you can no longer provide care to the dog you adopt, it must be returned to this organization.

                                                    I AGREE__________       I DISAGREE__________ 

The average Cocker Spaniel has a life span of 12-15 years. Are you willing to make a commitment to this dog for the rest of its life? Are you willing to provide the necessary love and attention as well as the necessary food, Vet care, and grooming required to maintain a happy Cocker Spaniel? ______Yes. ______ No.

 Please sign that you have read the above information and that you understand it. If you have any questions regarding the care and maintenance of a cocker spaniel please let the organization know. We will be more than happy to help with any questions you may have.

 SIGNATURE(S)_________________________________________________________________________t is extremely important that once a dog is placed in a new home that it remains there and that all parties involved are satisfied. Cocker Rescue is looking for COMMITTED FAMILIES ONLY. If you have any questions or concerns about adopting a cocker it is imperative that you finalize them before adopting.

______________________________________________________________                                                                Name of Prospective Adopter(s))                                                                                Date

                                                             TEMPORARY RELEASE OF RESCUE DOG:

I ____________________________________ am considering adopting the dog named _________________________ (hereinafter referred to as "the dog") from Oldies But Goodies Cocker Rescue, Inc. (hereinafter "OBG"). I understand and agree that within no later than one week from today, I will have a home check done and agree to either adopt or return the dog. I am aware that the adoption fee is $_____. I, the undersigned, hereby release and covenant to hold harmless OBG and its members from any claims, damages, costs or actions incurred as a result of this temporary release of the dog before the final adoption or transfer is completed.  I agree to supervise the dog around everyone, especially children, that come around while in my care. I agree to provide food, water and shelter for the dog while in my custody. I agree to provide emergency medical care if necessary, and will contact OBG as soon as possible to advise them of the circumstances. If the dog becomes lost, it is my responsibility to contact OBG immediately, and to contact the local shelter(s), put up signs in the immediate area, and canvas the area in an effort to locate the dog.

 ______________________________________________________________________________________                                       Signature of prospective adopter                                                        Date

Address: _____________________________________________________________________________________________

____________________________________________________________________________________________________