Heartland Golden Retriever Rescue - Adoption Application

PLEASE NOTE: A submitted application does not guarantee adoption of a Golden from HGRR; nor that the dog an applicant would like to adopt from HGRR, is the one that is best suited to meet their needs, and HGRR reserves the right to offer one they feel is better suited to match the application.

Name of Applicant/Dog's Primary Caregiver: _______________________________________________________

Spouse/Parent/Co-Applicant Name:  _____________________________________________

Mailing Address:  ________________________________________________________________________________

Street Address, city, state & zip (if different from above): ________________________________________________________________

Daytime phone: ____________________   Evening phone:  _______________________ Best time to contact:  _________   

Fax:  ______________________ email ________________________________________________

How many adults in the home?: ________  How many children in the home?:  _______    Ages?:  _____________ List any Step-Children, grandchildren, cousins, friends children and their age(s), that visit week-ends or vacations: 

__________________________________________________________________________________________________________

Are you aware that a dog of this size can easily knock down a child and/or the elderly?    yes____ no______  Is there anyone at home who may be adversely affected by a dog?   (allergies, etc.):  yes _____  no _____   Do all family members want this dog?  yes ____no___  Who will be responsible for the care of this pet?:  __________________

How did you you find us?  Past Adopter____   Veterinarian ______  Shelter/Humane Society _______  Internet ________  

Have you owned a Golden Retriever before?  yes______no________ Have you applied to another group for a Golden?  yes___  no___  If

yes, which group(s): ____________________________ Approximate date __________________________________ 

May we (or our representative) visit you at your home, prior to adoption? Yes____ No______

 Would you consider a senior dog? (i.e. one who required medication for a permanent but controlled condition, or one who blind, deaf etc?))  yes____ no____ Preferred age:  puppy____ young adult____  older adult____ senior____ no preference_____  Activity Level: High___ Medium___ Low___  Preferred sex:  male___ female_____ no preference____

Do you live in a:  House____    Townhouse/Condo____     Apartment____    Duplex____        Trailer____ Other__________   How long have your lived at your current address? ______ Do you: Own____ Rent____  Do you have the landlords permission to have a dog over 50lbs.? yes____  no____  *Landlord's name/address/phone (phone number MUST be provided):

 ______________________________________________________/phone #______________________________________________-

*Please give the name and phone number of the veterinarian you plan to use:  _______________________/_____________ *Pleass list all veterinarians you have used in the past 3 years (including their phone numbers)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Please list all of the pets you've had in the past 5 years (type, sex, age, spayed/neutered, where is it now?): 

________________________________________________________________________________________________________

_________________________________________________________________________________________________________

If you have had a pet die due to:  age, illness, euthanasia, accident, in the last 5 years  -- please give details:

_________________________________________________________________________________________________________

Have any of your pets ever been treated for heartworms? yes___ no___ - if yes please explain circumstances ____________________

______________________________________________________________________________________________________________

Are all dogs presently living with you on regular heartworm prevention? Please list type of medication; how often give; if not on preventative, please explain why:

________________________________________________________________________________________________________________

*Please give the names and phone numbers of two references: 

________________________________________________________/_______________________________ and

                                            ___________________________________/______________________________

*Note We reserve the right to call your landlord; do we have permission to check your vet reference as well as your personal references? Yes___ NO___  Please notify your vet that we may call and that you give your permission for us to check on past care of your animals.

Are you familiar with the use of a dog crate to train and/or confine the dog in your absence?  yes _____ no____  Are you willing to use a

 crate?   yes ____ no ____ How many hours a day will the pet be left alone? ___________________ 

Where will pet be kept during the day?  Be specific:  _________________________________ Where will pet be kept at 

night?  ________________________________________________  Is there anyone home during the day?  yes ____ no____

Do you have a fenced in yard?:  yes ____ no ____  Type of Fence: ________________  Height of Fence:  ____________      Will your dog be

 tied outside?  yes____no_____ Will your dog live in the yard?  yes_____ no______

If you do not have a  fenced yard? How will you exercise the dog? _____________________ Allowed to run free? (off your property) Yes ___ No___  Will your Golden be allowed in the house? Yes ___ No___   Will your dog be blocked off from certain portions of the house? yes___   no ____ be tied ourside? yes___ No___ live in the yard? Yes___   No___ Will your golden receive formal obedience training?  Yes ___ No___   Have you ever trained a dog before? Yes___ No___ Are your aware that Goldens shed all year long? Yes___ No___  Will you groom the dog yourself or use a groomer?  self____ groomer____  both____ Are you aware that routine costs of maintaining a dog averages ~$800-$1000 per year Yes___ No___

In the event you are unable to care for this pet in the future, who will accept responsibility for its care for the balance of its life?

 __________________________  Will rescue be notified?  yes_______ no__________  Have you sold, given away, or surrendered a pet to

 a shelter? yes_____ no____  If yes, please explain: _____________________________________________________________________________________________________________

Who will care for this pet while you are on vacation?:  ________________________________ If you move, what will you do with this pet?

 ______________________________________  Are you willing to take responsibility for this pet for 10 years or more of its life? yes____    no____   I

Please tell us why you want a Golden Retriever________________________________________________________________________

_______________________________________________________________________________________________________________

Do you have any special needs or wants? ____________________________________________________________________

__________________________________________________________________________________________________________   

Please feel free to add any other information that you think might be helpful to us in evaluating your application: 

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Thank you for taking the time to download our adoption application -- if you wish to pursue an application with Heartland please mail your completed application, together with a $25 application fee* to:

Heartland GRR, 1508 Bickerstaff Blvd,  Knoxville TN 37922

your application will not be processed until we receive this fee.

We will respond to your application as soon as possible; please remember that this organization is staffed totally by volunteers!

*Application fee - Please see Adoption Policy  Please read the Adoption Contract you will be required to sign at the time of adoption