Completed Date: Foster Adopt   Dog Name

                                                                      Dog Name


Name:          Home Phone:


City:           State:   ZIP:


Married:    Single:   Live with parents:    Age (if < 21):

No. of children in the home:    Ages:

Employer:   Work Phone:

Spouseís employer:  Work Phone:

Does your company have a matching grant for charitable organizations?


Does anyone in your family suffer from allergies?   Who?


Are you or your spouse in the military or reserves?


Have you applied to another rescue or shelter?



RESIDENCE:     House:       Apartment:       Condo:        Mobile Home:

          Townhouse:      Other:           Own:            Rent:

How long at this address?

If less than 2 years, please list  your previous address:

If renting, landlord name    And phone:

Besides your immediate family, are there others residing in your home?

          If yes, who?

Does your home have a yard?   

If you have a yard, is it Fenced?   Yes     No     

Height/Type of fence?

Is the fence attached to your home?

Do you have a dog door?



Are you familiar with the Dalmatian breed and their requirements?

When/where would you walk/exercise a dog ON leash?


When/where would you walk/exercise a dog OFF leash?


When you are home, where will the dog be kept?


When no one is home, where will the dog stay (be specific)?


What is the longest period of time the dog will be left alone?


Where will the dog sleep at night?


Who will be responsible for feeding and taking the dog outside?


Who will be responsible in the absence of the primary caretaker?


What reading or other steps have you taken to prepare for a new dog?

Are you willing to obtain an appropriately sized, open-wire crate?


What will you do if your newly adopted pet does not get along with your other pets for a while?


Have you adopted from a shelter or rescue group before?


If so, please provide details:


Are you willing to take time to housebreak a dog?

Do you understand that changing a dogís environment may cause the dog to have accidents? 


Will you take your dog to obedience classes? Where?


What type of veterinary care do you plan to provide?


Why do you want this particular dog?


What will you do with your dog if you move or go on vacation?


 What might cause you to return your adopted dog; i.e., job loss, children, move, divorce, etc.?



What will you do if your new pet chews things, dumps trash, etc.?


What will you do about the dog if you have a lifestyle change, such as a new baby?

Please check all of the following that will apply to your new dog: 
Watch Dog:      Companion:        Hunting Dog:        Guard Dog:        Family Pet:



OTHER PET INFORMATION: Do you currently have other pets?

1) Name:

Type: Age: Sex:

Indoor or Outdoor?

Year acquired:     Source:

2) Name:

Type: Age: Sex:

Indoor or Outdoor?

Year acquired:     Source:

3) Name:

Type: Age: Sex:

Indoor or Outdoor?

Year acquired:     Source:


Veterinarianís Name:       Phone:

<add any additional pets you have now, or have had in the last 10 years, at the bottom of this document along with any other vets used>



If your pets are cats and/or dogs, are they all spayed and/or neutered?

If not, why?

Are your pets current on their vaccinations?

Do any of your pets have an infectious disease now, or have they in the recent past?

If yes, what?


I certify that the information provided on this form is true and correct.  I am also financially able to care for this animal.  I understand that proper food and veterinary care will be costly and am able to meet these requirements.  I understand that a home check is mandatory prior to adoption and that follow ups may be conducted for up to one year.  I understand that any false statements constitute grounds for confiscation and surrender of the animal.  I further understand and agree that CCDAL may demand return of the animal for any violation of the terms of the adoption contract and agreement.  Should the animal be returned to CCDAL I understand that I will be responsible for any fees and expenses incurred in the reclamation of the dog, but not limited to legal and/or medical fees.

I have read and understand the above statement 


Printed full name(s):   Signed Date:



Rev.  7/7/05

Additional pets: