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ADOPTION QUESTIONNAIRE

ADOPTION IS A LIFETIME COMMITMENT

Please fill in all questions. If something does not apply, just enter n/a.

1. First Name
Your first name is required.
2. Last Name
Your last name is required.
3.Occupation
An entry is required.
4. Address
An entry is required.
5. City
An entry is required.
6. Zip code
Your zipcode is required.Invalid format.Minimum number of characters not met.
7. Home Phone- Area code first
Your home phone number is required.

8. Cell Phone-Area code first

Your cell phone number is required.

9. Work Phone-Area code first

An entry is required. Your work number is required.
10. Email
An email is required.Invalid format.
11. Spouse/Significant Other
An entry is required.
12. Spouse/Sig. Other Occupation
An entry is required.
13. Names/Ages of Children
An entry is required.
14. Name of the animal you are interested in adopting:
An entry is required.Minimum number of characters not met.
15. Does EVERYONE in your family want to adopt a dog?
Please select yes or no
16. If you live in a Condo or Apartment, does the association allow pets?
Please select an item.
17. If renting, do you have permission to keep a dog?
  Please select an item.
18. Please tell us the landlords name and phone #.
An entry is required.
19.What are your primary reasons for wanting to adopt a dog?
An entry is required.
20.If you have children, please describe their previous experience with dogs:
An entry is required.
21. Has any member of your family ever experienced animal-related allergies?
Please select an item.
22. Does your home have a pool?
Please select an item.
23. How do you introduce the dog to the pool?
An entry is required.
24. Do you presently have a dog?

(all dogs in the home must be spayed/neutered in order to adopt from Ken-Mar Rescue.)

Please select an item.
25. Have you previously had a dog?
Please select an item.
26. If you presently have dogs please list their name, breed, age & sex (or if they are neutered/spayed):
An entry is required.
27. If you have previously had dogs please list name, breed. Also write what happened to the dog.
An entry is required.
28. If you have other pets besides dogs, please list their species & ages
An entry is required.

29. Is there anyone home during the day?

Who?

An entry is required.
30.When will the dog be inside?
An entry is required.
31.When will the dog be outside?
An entry is required.
32.How many hours per day will he dog be left alone and where will it be when left alone?
An entry is required.
33. What rooms are off limits to the dog?
An entry is required.
34.What outside areas are available to the dog:
Please select an item.
35. Who would be responsible for the care of the dog?
An entry is required.
36. Where would the dog sleep?
An entry is required.
37. Where will the dog be left when he/she is alone or when you are away from your home?
An entry is required.
38. Is your yard fenced?
Please select an item.
39. Type of fencing
Please select an item.
40. Height of fence at its highest and lowest:
An entry is required.
41. Please tell us what kind of locks you have on the gates?
An entry is required.
42. Have you recently inspected your fence and is it secure, without holes, gaps, or low points? If NO, and your application is accepted, do you agree to thoroughly inspect your fence and make any necessary repairs before the home visit?
Please select an item.

Please select an item.
43. Who has access to your yard?

gardener

poolman

housekeeper

utility

neighbor

Select as many as apply.

44. Do you have a doggie door?
Please select an item.
45. Preferred level of exercise with dog?
Please select an item.
46. If currently have dogs what kind of food do you feed? Please list brand and type (dry or canned)?
An entry is required.An entry is required.
47. How would you rate your level of dog owning experience?
Please select an item.
48.How would you discipline your dog if he or she misbehaved?
An entry is required.
49.Do you understand that in adopting a rescue dog you may be dealing with hair on the furniture, possible stains on your rugs, a warm body on your bed, and an animal that might be destructive at times?
Please select an item.
50.Under what circumstances, if any, could you imagine would cause the return of your adopted dog?
An entry is required.
51. Name of vet and/or reference.
An entry is required.
52. How did you hear about our adoption program?
An entry is required.
53. Is there anything else you would like to tell us about yourself or your home environment?
An entry is required.
54. Do you agree to the Adoption Agreement? (download it here)


Please make a selection.

Leave this empty:


Problem with the form?
If you do not see the "Thank You" page after you click "Submit", you may have a field that is not filled out. Please scroll back up the form and check for any missing information. If a question does not apply, just put in N/A. Then click on "Submit" again. Still having problems, email us at:

Thank you for completing this Adoption Questionnaire
and for your interest in a Ken-Mar Rescue dog!

You too can help save a dog's life!