Seniors for Seniors Adoption Questionnaire

Best time / place to call   home   work   cell

Age select 62-70 71-76 77-82 83+   If you are under 62 years old, please STOP and fill out our standard Adoption Questionnaire instead.

Occupation

Employer

How would describe your energy level? select high medium low very low

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:

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

Google search  

Attended an event  

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

Social media

Which one(s)?
Facebook   Twitter   Instagram

Press

What kind?
TV   Radio   Publication   Non-Muttville website

Other  

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

How many adults (18 or older) live in your home? select 1 2 3 4 5 6+

Please supply names and ages of all adult occupants, including you.

How many children (under 18) live in or frequently visit your home? select 0 1 2 3 4 5 6+

What are the ages of these children?

Do you have a caregiver?   Yes   No

If so, please provide:

Do you:   own   rent

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

How many?

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

Will you allow us to visit your home?   Yes   No

Do you currently have other pets?   Yes   No

How many dogs currently live in your home? select 0 1 2 3 4 5 6 7 8 9+

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

How many cats currently live in your home? select 0 1 2 3 4 5 6 7 8 9+

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:

Name

Phone

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

CERTIFICATION

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.