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If you do not fill out a field with a red asterisk* you will get a validation error and the form will not be processed.

Fields marked with a red asterisk (*) are required

Name of the dog you are considering adopting*

Date*

Your Full Name (Include Middle Initial)*

Email Address*

Address*

City*

State*

Zip*

Home Phone (Include Area Code)*

Cell Phone (Include Area Code)*

Work Phone (Include Area Code)

Fax Number (Include Area Code)

Employer/Address/Phone Number

Work Hours*

Are you a full time Florida resident?*
YesNo

Seasonal resident?*
YesNo

Type of housing?*
Single Family HomeMobile HomeApartmentCondominiumTown houseVilla

Name of Development*

Does your Association permit pets?*
YesNo

Is a Deposit Required?*
YesNo

Deposit Amount

Weight Limit for Dogs, If Applicable

Do you own or rent?*
OwnRentN/A

If rent, do you have permission to have pets?
YesNo

If you rent, please provide the name and phone number of your landlord.

Do you have a fenced in yard?*
YesNo

Pool?*
YesNo

Do you plan on moving in the next year?*
YesNo

If you move, what will you do with your pet(s)?

Do you or does anyone in your household have allergies or asthma?*
YesNo

What member of the family will be taking the MAJOR responsibility of caring for this pet?*

List the names and ages of the members of your household. (Include yourself)*

If there are more than six people in the household please list them below where we ask for additional information.

Do you have any animals now?*
YesNo

Have you ever had a cat or dog?*
YesNo

(List all the animals you currently have)

If there are more than three animals in the household please list them below where we ask for additional information.

(List any animals that you have previously had and that are no longer with you)

If there are more than three animals that you have previously had and that are no longer with you please list them below where we ask for additional information.

Present Veterinarian/Address/Phone Number:*

Do you use heartworm prevention?:*
YesNoN/A

Have you ever turned a pet into an animal shelter or rescue?*
YesNo

If yes, why?

Is anyone home during the day?*
YesNo

If so, who?

Where do you plan on keeping your pet while you are at work or not at home?*

Are you willing to take your dog for training if needed or hire a trainer?*

How long will you give your new dog to adjust to its new home?*

If something happens to you (sickness, death, etc.) and you cannot take care of your pet(s) who will take care of them?*

When you go on vacation, where will your pet(s) go and who will care for them?*

Are you aware that we are not affiliated with any other rescue groups, and if you need to relinquish the Dog(s) that you adopted from us, please call Chesed Foundation, Inc. at 561-213-5773*
YesNo

Please supply the name, address and telephone numbers of two personal references (non-relatives).*

Any additional information you feel is important.

Applications are reviewed and pets are adopted to the applicant most suitable for that pet. It is not a first come, first serve process.

If you do not fill out a field with a red asterisk* you will get a validation error and the form will not be processed.