home > adoption application

To help ensure the best possible placement of our rescued dogs, and in order to determine that the proposed adoption is in the best interest of the dog, you, and your family, please complete each of the following questions. Please be as thorough as possible. The Brockton Blue Dog Shelter reserves the right to refuse adoption to any applicant.

Once the form is completed, you may may simply submit via email by choosing the submit button, or you may print it out and sign it and fax to (508-584-7801) or mail to (1014 Pearl Street, Brockton, MA 02301), or drop it by the shelter.
Adoption Animal
Which adoption animal prompted you to apply?
Personal Information
First Name: Last Name
Spouse's First Name: Spouse's First Name:
Home Phone:   Work Phone:  Cell Phone:      
E-mail:
Street Address:
City   State   Zip Code     
Employment
Occupation:   Years Employed:  
Employer:    Employer's Phone:
Your Home
What type of home do you live in?
  House Apartment Condominium Duplex Mobile Home
Do you own? or rent?
If you rent does your lease allow dogs? Yes No
Landlord's Name: Phone:
Length of time at current residence?
Less than 1 year (If this is selected, please provide previous address) Previous Address:
1-3 years
3-5 years
5+ years
Is your property fenced? Yes No

If you do not have a fenced yard, what arrangements do you plan to make for exercise and toilet duties?

Do you have a swimming pool? Yes No
How many adults live in your home?
How many, if any children live in your home?    What are their ages?
Does anyone living in your home have allergies? Yes No
If they do, how do you plan to accommodate your new pet?
Does anyone in your home have physical disabilities? Yes No
If yes, please explain:
Are all family members aware that you are considering adopting a dog? Yes No
Do they all approve? Yes No
Other Animals
Do you own other pets? Yes No      Total number of animals:
If yes please complete information below.
Animal 1
Name Type/Breed
Sex: Male Female ; Age

Neutered/Spayed? Yes No      Length of ownership:

Animal 2

Name Type/Breed
Sex: Male Female ; Age

Neutered/Spayed? Yes No      Length of ownership:

Animal 3

Name Type/Breed
Sex: Male Female ; Age

Neutered/Spayed? Yes No      Length of ownership:

References (No Relatives)
If you have listed other pets, you must provide Veterinarian information.
Veterinarian: Phone:
1st Personal Reference    Relationship:   Phone:
2nd Personal Reference    Relationship:   Phone:
3rd Personal Reference    Relationship:   Phone:
A Dog's Life
Will there be someone home with your dog during the day? Yes No
What is the greatest number of hours the dog will spend alone daily/nightly? hours
Where will the dog spend most of its time?
   Crate  Indoors  Outdoors  Garage  Basement  Run
Where will your new dog's main sleeping quarters be?
   Crate   Dog bed  Share bed with owner  Designated Room  Outdoors  Garage  Basement
Is there someone home at night? Yes No
Do you plan to travel with the dog? Yes No
If not, where will the dog stay while you are away?  Friend or Family  Kenneled  In home pet-sitting
Have you ever taken a dog to obedience classes? Yes No
Have you ever crate trained a dog? Yes No
How much do you think this dog will cost you each year? (please include food, heart worm preventative, flea control, medicine, medical and dental care, supplies, training, grooming, boarding costs, and toys)? $
Have you ever given up a pet for adoption? Yes No
If yes, please explain the circumstances:
Have you or anyone else in your home ever been convicted of OR charged with cruelty to animals,
child abuse or domestic violence? Yes No
Desired Animal
What type of animal are you looking for?
What sex animal are you looking for? Male Female No preference
What age animal are you looking for?
Would you accept a dog that has a treatable medical condition? Yes No
What type of activities do you plan for you and your dog?
 
I certify that I have read and completed the Adoption Application completely and accurately.
___________________________________________ (If mailing or faxing completed form)
Signature
 
I am over the age of 18, or have parental permission to adopt an animal. By submitting this form, I agree that it was completed accurately and completely.