My name is Samson-Pending!

Sampson is about 8-12 months old. He is a min Dachshund. He is about 10 lbs. He is small and will stay small. He is very eager to please anyone he meets once he warms up to you. He has started his house training and crate training. He also is learning to go up and down steps. He is being fostered with kids and does well with them. He is also being fostered with other dogs. He has been neutered, given 3 sets of 5-way vaccines, wormed, his rabies vaccine, and he is on heart worm and flea prevention. He will not be shipped or transported. If you are interested in adopting Sampson please copy and paste the application below into an email and email it to changingheartsrescue@aol.com.



Application:





Dog Adoption Application Form

Contact Information

Full name:



Occupation: ______________________________________________________________

Address: ______________________________________________________________



How long at this address:__________________________________________________



Daytime Phone: ___________________________________________________________



Evening Phone: __________________________________________________________



Best time to call: ___________________________________________________________



Email address: __________________________________________________________



Family & Housing

How many adults are there in your family (their relationship to you)?

_________________________________________________________________________



How many children (ages)?

_________________________________________________________________________



What type of home do you live in single family, town home, apartment, farm, etc.?

_________________________________________________________________________



Please describe your household: __ Active __ Noisy __ Quiet __ Average



If you rent, please give the rules governing pets and the landlord's name and number:



(by providing this information you are allowing CHR permission to contact your landlord please inform them of this call so they will speak with us)



Does anyone in the family have a known allergy to dogs? _________________________



Is everyone in agreement with the decision to adopt a dog? _________________________



Do you have time to provide adequate love and attention? _________________________

Other Pets



What other pets do you have (specify type and number)?





Are these pets up to date on vaccines? _________________________________________



Are these pets spayed/neutered? If not. Why?____________________________________



_________________________________________________________________________



Have you every surrendered a pet? If so, why?



_________________________________________________________________________



Have you ever had a pet euthanized? If so, why?



_________________________________________________________________________



Have you ever lost a pet to an accident?



_________________________________________________________________________



How do you discipline your pets and why?



_________________________________________________________________________

Veterinarian



Do you have a regular veterinarian? __ Yes __ No



Veterinarian's name: _______________________________________________________



Clinic Name: _______________________________________________________



Clinic Address: ________________________________________________________



Clinic Phone: ________________________________________________________



(Providing CHR with this information you are allowing CHR to call your vet. Please call your vet and ask them to authorize the release of information to CHR.)



















About the Dog You Wish to Adopt



What is your idea of an ideal dog and why?



Desired age: __________ Desired Size: _____________________________________



Desired breed: _______________________________________________________________



Breed you would not adopt:_____________________________________________________



Desired sex: _ Spayed Female _ Neutered Male _ No preference



Willing to adopt: __ outgoing/hyper dog __ shy dog

__ dog that needs regular medication __ dog that needs training

__ dog that needs grooming __ None of these









Where will the dog spend the day? (describe)

_________________________________________________________________________



Where will the dog spend the night? (describe)

_________________________________________________________________________



Number of hours (average) dog will spend alone? _________________________________



Who will have primary responsibility for this dog's daily care? _______________________



Who will have financial responsibility for this dog? ________________________________



Do you agree to provide regular health care by a Licensed Veterinarian? __ Yes __ No



Do you agree to keep the dog as an indoor dog? __Yes __No



When the dog goes out, how do you plan to supervise it? Fenced yard?



Do you agree to contact CHR if you can no longer keep this dog? __Yes __No



Are you be willing to let a representative of CHR visit your home by appointment?
__Yes __No



How did you hear about CHR? _____________________________________________________



Would you be interested in fostering? __Yes __No __Would like to know more















Personal References

Please list someone who is familiar with both you and your pets.



Name:

Address:

Phone:

Relationship (relative, neighbor, friend, etc.):



Name:

Address:

Phone:

Relationship (relative, neighbor, friend, etc.):



All of the information I have given is true and complete. This dog will reside in my home as a pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccinations under the supervision of a licensed Veterinarian.



___________________________ _________

(Signature) (Date)