Adoption Expression of Interest Questionnaire

This is a fairly extensive questionnaire to help us access the suitability of your home. We want to ensure the dogs we rescued end up in a loving family that will last a lifetime. We hope you’ll understand and answer the questions the best you can.

Name of the dog you're interested in:

Breed:

PERSONAL DETAILS

Full name *

Driver's Licence*

Date of Birth *

Your Email *

Mobile Number: *

Second Contact Number:

Address: *

Suburb & Postcode: *

Profession:*

Company Name:

Residency type: *
CitizenPROther (describe below)

Are you thinking of adopting for yourself?: *
YesNo (give details below)

YOUR LIVING ARRANGEMENTS

Do you live alone?: *
YesNo

Full Name Age Relationship Health Issues? (Asthma/Allergies, etc)

Is everyone at home happy and in agreement to getting a dog?: *
YesNo (give details below)

Are you renting?: *
YesNo

If you are renting, please provide your landlord/agent’s name and phone number contact details:
INCLUDE: Landlord's/Agent's Name, Company Address, Contact Number (and their email if available)

What type of home do you live in?: *
ApartmentAcreageHouseOther (give details below)

Do you have a yard or outdoor area? If yes, what is the approximate size of the outdoor area (sqm2)?*
YesNo

How high are your gates or fences? (cm)

Do you have a pool, hot tub or spa area?: *
YesNo

If you answered yes to the above question, is the area securely fenced so a dog can’t enter?:
YesNo

HOME ENVIRONMENT

On average, how many hours would the dog be left alone at home each day?

If you’re working, how many hours do you spend at work?

Where will you keep the dog if there’s no one at home?

If you have to go away for more than a day, where would the dog stay and with whom?

Where would the dog be kept mostly when there are people home?

Where will the dog be kept during the night?

How frequently would you be able to walk the dog and for how long each walk?

Do you plan to exercise the dog off lead? Please give details below:

Are there young children at home?
YesNo

Do you plan to have kids in the future?
YesNo

Do young children visit your home often?
YesNo

YOUR EXPERIENCE WITH ANIMALS

Do you currently have other pets?
Yes (describe below)No

SPECIES BREED SEX AGE

If you’ve had dogs in the past, tell us where they are now:

Give details of what happened to the dog you had. Information about the illness/injury, and what treatment was given, or how it was released to another party:

If you have in the past, or currently have a vet, can you tell us who they are? Name of practice, Address, Contact number:

If you have in the past, or currently use a dog groomer, can you tell us who they are?? Name of Groomer, Address, Contact number:

YOUR ADOPTION EXPECTATIONS

What are your reasons for wishing to adopt a dog?

What traits are you looking for in a dog? (Eg. Companionship, family dog, energetic, friendly, mellow, etc.)

What type of things do you see yourself doing with your dog for leisure and recreation?

PLEASE INDICATE YOUR PREFERENCE WHAT’S ACCEPTABLE OR NOT ACCEPTABLE TO YOU

Description Acceptable / Not Acceptable
  Not housetrained
  Digs
  Excessive barking
  Chews on things
  Jumps fences
  Separation anxiety
  Fearful of new things
  Aggression towards other dogs
  Chase cats
  Not lead trained
  Chase livestock
  On-going medical problems
  Sheds
  Minimal obedience training

Thank you for taking the time to complete this form. We understand that you may not wish to provide all personal details at this stage; they can be completed once you have spoken to our adoption representative and the decision to proceed with an adoption is made.

Please leave this field empty.