Online Adoption Application

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For problems or questions regarding the online adoption application, please contact the GoldHeart webmaster at webmaster@goldheart.org.

Due to technical difficulties, applications submitted from 1/4/08 to 1/13/08 were not transmitted to the adoption team. If you submitted an application during that time, please resubmit your form. Repayment is not required as the payment process was successfully completed. We apologize for the inconvenience and appreciate your help in resolving this issue.

I would like to apply to Adopt a Golden Retriever
I would also like to apply to participate in the Foster-To-Adopt Program*

* Adopters that choose to participate in the Foster-To-Adopt program must agree to all of the conditions of this program. Visit our Foster-To-Adopt page to read more about this program. The adoption process for GoldHeart includes completing this application and a home visit. Please allow at least 3 weeks for processing. An Adoption Team member will contact you to set up a convenient time to come to your home, meet with you and your family, and answer any questions you may have about adopting a GoldHeart Golden Retriever. Please attach a separate sheet with information that you feel is pertinent, or to explain answers more fully.

Applicants must be 21 years old.

Applicant's Contact Information		Co-Applicant's Contact Information (Optional)
First Name:		First Name:
Last Name:		Last Name:
Occupation:		Occupation:
Age:		Age:

Address:
City:		Zipcode:
Home Phone:		Work Phone:	(optional)
Cell Phone:	(optional)	Email Address:

Please list any other adults living in the home and their relationship to the applicant:

1. Type of Residence:
If other is selected, please explain:

2. Do you own or rent?	Own Rent
A copy of your lease or a notarized statement from your landlord confirming a large dog is permitted is required for approval.

3. How did you hear about GoldHeart?
If other is selected, please explain:

4. Have you applied to another rescue?	Yes No
If yes, which rescue?
How long ago?
Were you approved to adopt?	Yes No
If you were not approved, provide the reason(s) you were not approved:

A successful adoption depends on selecting the right Golden for your household and a good understanding of the dog's needs and care requirements. Please help us with this process by answering the following questions fully and completely. An area is provided at the bottom of this form for you to convey to us any additional necessary information you can't fit in the space provided on the form.

5. Why do you want to adopt a Golden Retriever?

6. What will the dog be used for?
If other was selected, please explain:

7. Please list all pets currently residing in your home. Please provide information on their temperament and any special needs.

If none of your current pets are dogs, have you owned a dog as an adult? Yes No

As an adult, have you ever owned a golden? Yes No

8. What age Golden do you prefer?

9. Would you prefer a male or female? Male Female No Preference

10. Would you consider adopting a special needs dog that required medication for a permanent but controlled condition? Yes No Possibly Not at this time

11. On a scale of 1 to 5 (with 5 being the most energetic), what activity level would best fit you family situation? 1 2 3 4 5

12. The annual cost of vet care, food, and supplies for a healthy dog can easily cost $1,000 a year.
Does this fit within your family budget? Yes No

13. Do you have a completely fenced yard?	Yes No
If yes, what type of fence?
Fence height?
If you do not have a fence, would you consider installing:
A conventional fence?	Yes No Possibly
An invisible fence?	Yes No Possibly

14. How will you exercise your dog?
Where will you exercise your dog?
How often will you exercise your dog?
Who will supervise the dog during outdoor activities?
Will the dog be allowed off leash?

15. Would there be any circumstances where the Golden would be tied or left outside for exercise or potty breaks? Yes No

If yes, under what circumstances?

16. Do you have any of the following?
A dog door?	Yes No
An outside Kennel?	Yes No
A dog run?	Yes No
Tieout?	Yes No
An overhead Cable?	Yes No
Dog House	Yes No
If you have any of the items in question 16, please provide information on how they would be used.

17. How many children are in the home?
Their ages?
Do they have experience with large dogs?	Yes No

18. What will be the children's involvement in caring for the new Golden?

19. Do you provide child care in your home? Yes No

How often, and how many children?

20. Where will the dog stay when no one is at home? Be specific.

21. Where will the dog sleep at night? Be Specific.

22. Is someone home during the day?	Yes No
If yes, who in your household?
If no, how many hours each day will the dog be alone?

23. Are your other pets up to date on vaccinations and Heartworm preventative? Yes No

If not, please explain why?

24. Describe a typical day in your household.

25. Who will be the primary care giver(s)?
Who will be the secondary care giver(s)?

26. Who will care for your Golden while you are on vacation?

27. If you move, what will happen to the Golden?

28. Are you prepared and willing to be responsible for the care of the Golden for the next 10 or more years of their life? Yes No

29. Does anyone in the household have allergies? Yes No

Have asthma? Yes No

If yes to either, how is it controlled?

30. Have you ever attended obedience classes with a former or current dog? Yes No

Attended agility classes? Yes No

31. Would you be willing to attend obedience classes with your new dog? Yes No

If you are unwilling to attend obedience classes with a new dog, please provide your reasons.

32. Have you ever participated in K9 sports with a dog? Yes No

If yes which one?

33. Have you ever crated a dog? Yes No

If yes, when?

34. Would be willing to crate the new dog? Yes No

35. If you prefer not to crate a dog, please explain why.

36. Have you ever had a dog stolen, lost, or die prematurely? Yes No

If yes, please explain the circumstances:

37. Have you ever sold or given away a pet? Yes No

If yes, please explain the circumstances:

38. Have you ever surrendered a dog to a shelter? Yes No

If yes, please explain the circumstances:

39. Provide the names, and telephone numbers of at least two non-family references.

40. Provide the name, address and telephone number of your current veterinarian. If you do not currently have a veterinarian, provide contact information for the veterinarian you intend to use in the future and identify them as a new one.

41. If you have additional information you would like to include, please enter it in the box below.

42. Do you affirm that all of the information provided herein is accurate and complete? Yes No

43. I will pay the $20.00 application fee by:
The application will not be process until the application fee is received.

Providing false or misleading information is grounds for immediate and permanent disapproval of your application.

Don't press the "Submit" button until you have completed your application. If it is successfully submitted, you will see a confirmation page.

© 2008 - GoldHeart Golden Retriever Rescue
GoldHeart is an all volunteer, non-profit 501(c)3 organization dedicated to the rescue of unwanted Golden Retrievers
P.O. Box 206, Mount Airy, Maryland, 21771, 410-877-9697, webmaster@goldheart.org
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