GRAPE Rescue

APPLICATION FORM

Applicants Name: Applicants Age:
Co-Applicants Name(s): Co-Applicant(s) Age:
Street Address:
City: State: Zip Code:
Daytime Telephone #:
Evening Telephone #:
Best Time To Contact You:
E-mail:
Who Will be Golden's primary caregiver (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?:
Is the pet for (check all that apply) an: Adult Child Elderly person Physically Challenged
How did you learn about our rescue?:
Do you live in a (check one): House Townhouse Apartment Duplex Mobile Home Condo
Do you: Own Rent
Do you have the landlord's permission to have a dog over 50 pounds?: Yes No
Do you have a fenced yard: Yes No
Fence type and height:
Where will the golden stay during the day? Where will the golden stay during the evening?
Is there 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 a Golden Retriever:
is a large dog that may jump up and knock down someone? Yes No
is active and shed year-around? Yes No
Please list all other pets in household: Name Type Age Sex Altered
Have you ever sold, given away or surrendered a pet to a shelter? Yes No
If so, please describe circumstances?
Do you plan to take an obedience course with your dog? No
Have you ever taken one? Yes No
Are you aware that the routine costs of maintaining a dog average $600 to $800 a year?
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.
Applicants Signature:
Co-Applicants Signature:
Three personal references we may contact:
Name and Phone number
1.
2.
3.
Age range interested in adopting: (Check all that apply)
Any Age Puppy (0-2 years) Adult Senior (9+ years)
Preference: Male Female No preference
Would you consider a golden mix? Yes No
Would you consider a special needs dog, such as one that requires medication for a permanent but controllable medical condition? Yes No
Have you applied to any other Golden Rescues? Yes No
If yes, which one(s)?

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In addition to your application please send us a detailed letter about yourselves and why you want to adopt a Golden Retriever? Please include any information about special activities in which your rescue dog would be included. Also, if you have any special requirements for a dog, please let us know so we can carefully match the dog to its "forever home."

If, for any reason, the adopter should not be able to keep this dog, he/she is obligated to return the dog to Golden Retriever Adoption, Placement & Education. The continuation of this program relies upon donations for medical and foster care for these homeless dogs. At the time of adoption, a non-refundable donation of $250 is appreciated. This money is used to help pay costs for homeless Goldens who enter our program.

Adopters are not selected on a first come basis. We strive to choose the most compatible environment for our Golden rescues. We reserve the right to refuse an adoption to any applicant. Adopters must be over 21 years of age.

I understand that by signing this contract, I am taking sole responsibility of the rescue Golden. Golden Retriever Adoption, Placement & Education is not liable or responsible for any damage to persons or property once this contract is signed. I am signing and adopting the Golden of my own free will and not under duress of any kind. If the Golden is being neglected or abused Golden Retriever Adoption, Placement & Education reserves the right to reclaim the dog.

Applicants Signature:
Co-Applicants Signature:

NOTE: Your application "WILL NOT" be processed until the application(Donation) fee is received.

You may apply online using paypal by clicking on the button at the bottom of the page or by mailing your application along with a non-refundable $25 application fee to:

GRAPE
PO Box 124
Springfield, PA 19064

E-mail at GRAPE_Rescue@yahoo.com.

You must submit the application, then submit the paypal.

Thank you for your interest in helping give a loving "forever home" to a needy Golden Retriever.

Adopted

FOR OFFICE USE ONLY:
Vet Reference check by: ___________________________ Date: ___________

Reference Check #1 by: ___________________________ Date: ___________

Reference Check #2 by: ___________________________ Date: ___________

Reference Check #3 by: ___________________________ Date: ___________

Home visit by: ___________________________ Date: ___________

Approved Date: ________________________

Disapproved Date: _________________

Comments:

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GRAPE • PO Box 124 • Springfield, PA 19064 • E-Mail: grape_rescue@yahoo.com