Adoption Form

Name of dog you are applying for:

All potential adopters/foster homes are screened for suitable placement of animals. SAMM may refuse placement of an animal for any reason. By submitting this application, you give permission for SAMM to investigate and confirm the information that you provide. All forms become the property of SAMM upon submission.

Release for Veterinary Reference: (to be completed by potential adopter/foster)
I, , hereby give permission for any veterinarian providing service to me to release medical information on any/all of my animals to SAMM.

My current veterinarian is located at :

and can be reached at telephone number:

All form items marked * MUST be completed or your application will not be submitted.

1 Adopter Name*
2 Date of Birth* (MM/DD/YYYY)
3 Email Address*
4 Street Address*
5 City, State, Zip*
6 Home Telephone
7 Employer Name
8 Employer Address
9 Employer Phone
10 Years working for current employer
11 Spouse Name
12 Spouse Employer
13 Employer Phone
14 Please provide two references
(name, address and telephone number)

15 I live in
16 Do you have a fenced yard?
17 Type of fence
18 Fence Height:
19 How long at current address: years months
20 Do you own your home?
21 Do you plan to move in the next 12 months?
22 If Yes, where:
23 If you rent: Does your landlord allow pets?
24 Is a pet deposit required
25 How much: $ /per pet or $ /per household? Size/Weight limit?
26 Limit to number of pets?
27 Name of Apartment Complex or Landlord:
28 Phone:

29 Number of adults in household:
30 Number of children in household and ages:
31 Do all of the adults in the household consent to this adoption?
32 Are you or your spouse a student?
33 If yes, full time or part time
34 Do you or your spouse travel frequently?
35 If yes, how often:
36 Does anyone living in your house have asthma?
37 Does anyone living in your house have allergies?
38 If yes, to what?

PET OWNERSHIP

1 This pet will be kept:
2 How long will this pet be left home alone during the day? hrs days
3 Where will this pet be kept while you are at work or away from home?
4 Where will this pet sleep at night?
5 Are you willing/able to enroll this pet in an obedience class if needed or advised?
6 Are you willing/able to purchase and use a cage/crate if needed or advised?
7 Do you have a pet door?
8 Do you plan to chain this pet in the yard?
9 Can you keep this pet away from other pets in the house for one week?
10 How will you teach housebreaking (if necessary)?
11 Who are you getting this animal for? Self As a gift for
12 What will you do with this pet if you have to move?
13 What will you do with this pet when you need to travel?
14 Do you want this pet to be spayed/neutered?
15 Why would you like to add a dog to your family at this time?
16 What qualities are you looking for in the dog that you would like to adopt?
Be very specific (very active vs. couch potato; want to do obedience work/agility/flyball; etc.) so we can make the best match possible
17 What do you expect to be the worst and/or hardest part about adopting a rescued dog, and how do you plan to deal with/address it?
18 Does anyone have any concerns about adopting this pet? If so, who and what are the concerns?
19 Do you give permission for a SAMM representative to visit your home prior to adoption to do a home check and after adoption to do follow up checks on your adopted pet?
20 How much would you be willing to spend on vet care in the event of an emergency (example: dog swallows something and requires surgery)
21 Under what circumstances would you have a dog euthanized?
22 What plans have you made for your pets in the event you should pass away before they do?

PET OWNERSHIP HISTORY

1 Have you ever adopted from a humane group or shelter?
2 If yes, whom did you adopt from:
3 When?
4 Phone #:
5 Have you ever given an animal up for adoption or gotten rid of an animal?
6 If so, why?
7 What did you do with the animal?

8 Are all the pets in your household current on their shots?
9 Are all your dogs on Heartworm preventative?
10 What kind of Heartworm Preventative do you use?
11 What is the date of the last Heartworm preventative given?

12 Have any pets in your household been diagnosed with infectious diseases or conditions?
Heartworms
Distemper
Parvovirus

Please list all pets currently owned OR owned within the last ten years

1 Dog or Cat
Breed
Male or Female
Age
Length of ownership
Was it spayed/neutered?
If not, why:
Do you own the pet now?
If no, what happened to it?
This pet was kept:
2 Dog or Cat
Breed
Male or Female
Age
Length of ownership
Was it spayed/neutered?
If not, why:
Do you own the pet now?
If no, what happened to it?
This pet was kept:
3 Dog or Cat
Breed
Male or Female
Age
Length of ownership
Was it spayed/neutered?
If not, why:
Do you own the pet now?
If no, what happened to it?
This pet was kept:
4 Dog or Cat
Breed
Male or Female
Age
Length of ownership
Was it spayed/neutered?
If not, why:
Do you own the pet now?
If no, what happened to it?
This pet was kept:

Where did you hear about SAMM?

Important! You MUST tick this box to send your application.

By ticking this box you effectively sign and confirm that all the information in this application is correct and complete to the best of your knowledge. Any information supplied is used soley in connection with the SAMM adoption process. We do not share your information with any third party or contact you concerning matters other than the adoption.

 Please check you have answered all relevant questions prior to sending.

Dogs rescued since 2001

Animals Neutered / Spayed

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