Page Title

Name of Dog:

Your Name:

Your Age:

Email Address:

Our first attempt to contact you will be via email. MAKE SURE YOUR
EMAIL ADDRESS IS CORRECT !!!!!!!

Confirm your
Email Address:

Your Street Address:

City, State, ZIP:

Home Phone:

Work Phone:

List names and ages of other adults in home and their relationship to you:

Names and ages of Children:

Your occupation and the name of your employer:

Your spouse’s occupation and the name of his/her employer:

Type of Home:

Do you own or rent your home? (select one):

If you rent, Landlord name and phone:

Do you have a Yard?

Is it Fenced?

Age, Type, Height of Fence:

Where will the dog stay when you are not at home?:

How many hours a day will the dog be home alone:

Where will the dog sleep at night?:

What do you do with your animals while on vacation?

List other animals currently in your home (breed, age, sex. neutered/spayed,
temperament with animals and people.

Please list prior animals and what happened to them. Include breed, age, name.

Reference #1

Reference # 2

Please list 2 personal references. Include name,
address, phone and their relationship to you
(relative, friend, etc.)

Please list your veterinarians name, address and phone number:
This is a requirement. If no vet (with a history of animal care in your
name) is provided, your application will not be processed.

May we contact your veterinarian for a reference? (Please note - a verifiable
veterinary reference with a current history in your name is required.)

Please describe any situations that would cause you to give up a pet.
If you have done so in the past, why? Where and how did you find a
new home for your pet:

Are you agreeable to returning the dog to Just A Touch Rescue if you are no longer able to keep the dog?

Why do you want to adopt a rescued/puppy mill dog?

Why do you want to adopt this particular dog?

Do you agree to microchip the dog for identification purposes, and to provide Just A Touch Rescue
with verification of the microchip?

Please note that we can not guarantee that our dogs are or ever will be houstrained.
Do you understand this and are you still committed to adopting this dog for the
remainder of its life? Even if "accidents" happen every day?

Are there any other things we should know
about you, your family, your pets, etc.?

What amount of money are you willing to donate to adopt a rescued dog?
(please note that our adoption donation amounts usually range from
$400 to $500)

Are you agreeable to signing an adoption contract for the adoption of this dog?

By signing below, I declare that the information I have provided in this application is complete and correct. I
further declare that I am financially and physically able to care for a rescued dog, specifically, a special needs
dog. I understand that proper food and veterinarian care may be costly, and I am able and willing to meet the
needs of my adoptive dog. I understand the requirement and grant permission for Home Checks at random
both prior to and following adoption. I submit that if a Home Check reveals falsification or misrepresentation of
any facts on my part, Just A Touch Rescue (the rescuer), reserves the right to either refuse adoption or to
nullify the adoption and reclaim the dog from my premises, without reimbursement of the adoption donation. I
understand that Just A Touch Rescue (rescuer) can provide the veterinary history from the time the dog came
into its care, but can not make any claims or guarantees regarding the dogs past history and/or any possible
future problems. I agree that by submitting this application, I release Just A Touch Rescue (the rescuer), from
any liability that I may incur from the adoption of this animal and from any liability regarding behavioral
problems, including but not limited to, aggression towards other animals and people (including biting), and
property damage. I understand that pet ownership is a lifetime commitment and responsibility and that I am
adopting a family member for the remainder of its life.