Adoption Questionnaire

ACD Rescue Association

Adoption Questionnaire

Please copy and paste into a new e-mail

or print and mail to the appropriate foster home.

Please fill in completely:

HOW DID YOU LEARN ABOUT OUR RESCUE? ___________________________________

WHAT MADE YOU CHOOSE THIS BREED AS THE DOG FOR YOU?_______________________________________________________

HAVE YOU EVER OWNED AN AUSTRALIAN CATTLE DOG? _______________________

YOUR NAME _________________________________________________________________

SPOUSE/HOUSEMATE _________________________________________________________

E-MAIL ADDRESS___________________________________________________

STREET ADDRESS ____________________________________________________________

MAILING ADDRESS ___________________________________________________________

HOME PHONE ________________________________________________________________

EMPLOYER NAME ____________________________________________________________

EMPLOYER PHONE _____________________ EMPLOYED HOW LONG? ______________

SPOUSE/HOUSEMATE EMPLOYER NAME _______________________________________

EMPLOYER PHONE _____________________ EMPLOYED HOW LONG? ______________

PERSONAL REFERENCES: Please list three (3) with phone #

______________________________________________________________________________

How long have you lived at this address? ____________________________________________

How long do you plan to live at this address? _________________________________________

How long do you plan to reside in this area? __________________________________________

Number of children in household & ages: ____________________________________________

Do the children live there full time? _______________ If no, when? _______________________

Do you have tenants or relatives living with you? ______________________________________

Do you live in a: House ( ) Apartment ( ) Farm ( ) Mobile Home Park ( )

Do you own? _______ If renting, do you have WRITTEN permission to have a house dog on the premises? _______ Please attach copy.

Do you have a yard that is: Perimeter fenced ( ) Yard fenced ( ) (Does a house door open into the fenced area? ___ Kennel run ( ) No fence ( )

Fencing material used: Block wall ( ) Chain-link ( ) Welded wire ( ) Chicken wire ( )

Wood ( ) Other ( ) __________________

Please specify height of fence and linear dimensions: ____________________________________

How many gates? ___________ Height of gates: ___________ Are they kept locked? _________

Do you have secure screens on all your windows? ________________

Will the dog be primarily: Inside ( ) Outside ( )

Where will the dog sleep at night? __________________________________________________

What shelter will be provided outside? Patio ( ) Shed ( ) Doghouse ( ) Garage ( )

Other ( ) please specify _________________________________________________________

Is there shade in the dog's area at all times during the day? ______________________________

Do you have a swimming pool? ____ If yes, is it fenced separately from the rest of the yard?____

What is the primary reason you are considering an ACD? Watch dog ( ) Breeding ( ) Companion ( ) Guard Dog ( ) Child pet ( ) Obedience ( ) Herding trials ( )

Ranch work ( )

Do you have a preference for sex, age, color, personality? _______________________________

______________________________________________________________________________

Are there any specific habits or problems that you are not willing to deal with? _______________

______________________________________________________________________________

Do you believe a pet should be spayed/neutered? _____ If no, please explain ________________

______________________________________________________________________________

Please list all animals you presently own:

Breed How & Why obtained Time Owned Sex S/N Vacc/Lic

______________________________________________________________________________

Who is responsible for the care of these animals? ______________________________________

If you go away for a few days or on vacation, who will care for these animals? _______________

______________________________________________________________________________

How many hours a day will the animal be left unattended? _______________________________

Does anyone in the family have allergies to animals? ____________________________________

Who is your regular veterinarian? Name/address/phone# ________________________________

_______________________________________________________________

What is the activity level in your home?

( ) Busy - visits by friends, meetings, children, parties at home

( ) Noisy - T.V., stereo, machinery, tools, lots of kids playing

( ) Moderate - normal comings and goings

( ) Quiet - "homebodies", few guests

If you have previously owned pets, please fill in the chart below:

Breed How & Why obtained How long kept What happened to Pet

______________________________________________________________________________

Under what circumstances would you NOT keep the pet? New Job ( ) Move ( )

New Baby ( ) Divorce ( ) Illness ( ) Other ( ) please explain ____________________

______________________________________________________________________________

An immediate health check is essential for the welfare of the dog and your peace of mind. This needs to be done within the first five (5) working days of taking your dog home. Considering the high cost of veterinary are, are you willing and able to afford the necessary medical care and further vaccinations necessary to keep your dog healthy? _________________________________________

Will you keep this pet up to date on vaccinations and licensing? ___________________________

Have you ever purchased a rescue dog in the past? ____ if yes, did you have any problems?_____

Please explain: _________________________________________________________________

Pet ownership is a serious responsibility. The whole family needs to be involved in the decision to get a dog. Our policy is to insure that each person who adopts a dog not only be aware of that responsibility, but that each person be willing and able to accept this responsibility morally, physically and financially. We have found that not every person who desires to own an ACD should own one. They are an active and sometimes aggressive breed, but wonderful in the right home.

This questionnaire was designed to aid both you and us in determining if you and your family are indeed adequately prepared to assume the type of responsible pet ownership we are endeavoring to provide for our rescue dogs.

Please read carefully and sign:

I understand that there will always be an adjustment period for any dog coming into my home. The average is three (3) weeks to three (3) months and I am willing to work to make this pet a member of the family. I also understand that many of these dogs have survived tremendous odds and needs lots of TLC.

I understand that, ACDRA reserves the right to check on the welfare of this dog on my premises, and to reclaim both possession and ownership without payment of any kind with or without court action. In the event I do not comply with the adoption contract provisions and ACDRA reclaims the pet, I waive claim for trespasser damage that I might otherwise have arising out of such reclaiming.

I also agree that if the information given on this questionnaire is not accurate to the best of my knowledge, I forfeit all rights and ownership of the ACD adopted from the ACDRA.

I also agree that if at any time in the future I can no longer keep this dog, I will not give it away or sell it. I will contact ACDRA for arrangements to be made for the dog's return to them.

I have read completely the above questionnaire, and understand it fully.

Applicant Signature _____________________________________ Date__________________

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