Elders on the Edge Pet Adoption Form

ELDERS ON THE EDGE ADOPTION FORM 

You can fax this completed Form to Lela Jordan at (561) 835-7183, or you can scan completed form and e-mail to ljordan@wpb.org, or you can hand deliver or mail to:  Vickers House, 3801 Georgia Avenue, West Palm Beach, FL  33405, Attn.:  Lela Jordan.

In order to be considered as an adopter, you must:

  • Be 21 years of age or older
  • Have identification showing your present address
  • Have the knowledge and consent of your landlord
  • Be able and willing to spend the time and money necessary to provide training, medical treatment and proper care for a pet.

Completion of this application does not guarantee adoption of an Elders on the Edge dog or cat.

Thank you!

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Name: ___________________________________________________________________

Address:  ________________________________________________________________

City:__________________________________State: ____________  Zip code: _________

Phone: (_____)___________________  Alternate Phone: (_____)____________________

E-mail:______________________________________________________    Age:  ______

 Who is your Veterinarian? __________________________________________________ 

Telephone: (____)__________________City: ____________________________________

May we contact your Veterinarian for a reference? ________________________________

How long have you lived at this address?  _______________________________________

 Are you interested in adopting a dog or a cat? If more than one, please describe

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Are you adopting for yourself or for someone else?  _______________________________

Would this be your first dog or cat?   ___________________________________________

What kind of pets have you had in the past?_____________________________________

Which of these do you still have? (include age, sex and breed)  _____________________

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Have they been spayed or neutered?  __________________________________________

Are they current on vaccinations?  ____________________________________________

What happened to the ones you no longer have? _________________________________

Have you ever turned your dog or cat into a shelter? ______________________________

If yes, please explain________________________________________________________

Have you had a pet euthanized? ______________________________________________

If yes, please explain________________________________________________________

If you have other pets, will they (or it) adjust to a new pet entering the household?  ______

Was your last dog obedience trained? _________________________________________

Why do you want this dog or cat?  ____________________________________________

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Other reason details: _______________________________________________________

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How many adults are there in your family? ____ How many children? ____ Children’s ages:   _________

Does any member of your household have an allergy to dogs or cats?   _______________

Is someone home during the day?  ___________________ Who?   __________________

How many hours each day will the dog or cat be without human companionship?  ______

Explain:  _________________________________________________________________

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Do you own or rent your home? ______________________________________________

If you rent, may we contact the owner to obtain permission for this animal to live in your home?  _______

Owner’s name and phone number:

Name:  __________________________________________ Phone: (___) _____________

Do you have a completely fenced yard?  ________________________________________

What kind of fence? __________________________________ Height: _______________

Is there a gate? _________ If no, explain: _______________________________________

Do you have a dog door?____________________________________________________

Do you have screens on your windows?________________________________________

Are there stairs that lead to your home?_____________________ If yes, how many?____

Are there times when the dog will be tied up? ____________________________________

If yes, when?  _____________________________________________________________

Where will your dog or cat live?  ______________________________________________

Will the dog spend any time in the garage? ______________________________________

If yes, explain:  ____________________________________________________________

Do you have a pool?  ___________ If yes, is there a fence around the pool? ___________

If your new dog/puppy is not housebroken, what method will you use to train it? _________

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If your cat is not litter box trained, how will you train it? _____________________________

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Will you keep the dog or cat up-to-date on vaccinations? ___________________________

Have your cats been tested for leukemia? ______________________  FIV? ___________

Are they declawed? ______________  Where is the cat declawed? __________________

Under what circumstances would you have your cat declawed? _____________________

Are you aware of the potential side effects of declawing a cat?  ______________________

Would you be able and willing to exercise the dog or cat on a regular basis?  ___________

Method:  _________________________________________________________________

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Where will this dog or cat be kept during the day?  ________________________________

During the night?  __________________________________________________________

If you drive a pick up truck, would you allow the dog to ride in the back? _______________

If you go away for a few days, or on a vacation, who will take care of the dog or cat?  ____

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If you move, will you take the dog or cat with you? ________________________________

Explain __________________________________________________________________

How much are you willing to spend on medical bills for your dog or cat? _______________

What would you do if the Vet bills go over this amount?  ___________________________

What is your current occupation? _____________________________________________

Name of employer: _________________________________________________________

Does your job require extensive travel? _________________________________________

Did anyone refer you to Elders on the Edge?  If yes, please explain __________________

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Are you willing to allow a Vickers House representative to see where the dog or cat will be living? ___________________________________________________________________

Are you willing to take responsibility for this dog or cat for the next ten to 20 years?   _____

What provisions will you make for the dog or cat should you become unable to care for it?

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Is there anything else you would like us to know?  ________________________________

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OFFICE USE ONLY:

 

Date received: ­­­­­­­­______________________________

 
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