Seniors for Seniors Adoption Questionnaire

IMPORTANT: This questionnaire applies only to senior applicants interested in participating in our Seniors for Seniors Adoption Program. If you are under 62 years old, please fill out our standard Adoption Questionnaire instead.

Please answer the following questions so that we can make a great match for you and your new animal companion. There are no wrong answers! Contact us if you have problems or questions in filling out this questionnaire.

First name

Last name

Best time / place to call home work cell

Age If you are under 62 years old, please STOP and fill out our standard Adoption Questionnaire instead.

What are your preferred pronouns?

Are you a veteran? Yes No

How would describe your energy level?

Do you have limitations with regards to vision, hearing or mobility? If so, please provide details.

Are you filling out this questionnaire yourself? Yes No

If not, please provide the following information about the person who is assisting you:

Assistant's first name

Assistant's last name

Assistant's email

Assistant's telephone

Assistant's relationship to adopter

Who should be our primary contact regarding this questionnaire?

What Brought You To Muttville

How did you hear about Muttville? Check all that apply.

Walked by and saw Muttville signage

Referred by someone connected with Muttville

What relationship does this person have to Muttville? Check all that apply.
Volunteer Adopter Foster parent Staff member Fan

Which one(s)?
Facebook Twitter Instagram

What kind?
TV Radio Publication Non-Muttville website

What Muttville dog(s) are you interested in?

Have you ever had a dog before? Yes No

Do you prefer a: male female either is ok

What size dog do you prefer: small medium large any size is ok

What breeds have you been considering?

Where will your dog stay during the day / during the night?

In what activities do you plan to participate with this dog?

How will you discipline your dog?

Is any member of your household allergic to dogs? Yes No

Including you, how many adults (18 or older) live in your home?

Please provide your birthdate and the name, age, and relationship to you of each adult occupant of your home:

2nd adult occupant

First name

Last name

3rd adult occupant

First name

Last name

4th adult occupant

First name

Last name

Additional adult occupants

How many children (under 18) live in or frequently visit your home?

What are the ages of these children?

Do you have a caregiver? Yes No

If so, please provide:

Caregiver's name

Caregiver's email or telephone

If you rent, do you have written permission from your landlord to have a dog? Yes No

Do you have stairs inside or leading into your home? Yes No

Do you have a pool? Yes No Is it fenced? Yes No

Will you allow us to visit your home? Yes No

Current Animals in Your Home

Do you currently have other pets? Yes No

How many dogs currently live in your home?

Please supply the age and breed of each dog currently in your home.

How many cats currently live in your home?

Please describe any other pets you currently have.

Have you ever given up a dog? If yes, please explain the circumstances.

Please provide an emergency contact:

Is there anything else you'd like us to know about you or the kind of dog you want to adopt?

I certify that, to the best of my knowledge, the information provided in this questionnaire is true and complete. I recognize that any misrepresentation of that information will result in my losing the privilege of adopting a rescued dog from Muttville. I understand that Muttville has the right to deny my request to adopt a dog, and I authorize checking all information provided in this questionnaire.

Seniors for Seniors Adoption Questionnaire

General Information

What Brought You To Muttville

Your New Dog

Living Situation

Current Animals in Your Home

Emergency Contact

Additional Comments

Certification

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