Which dog(s) interest you?

Are you applying for the Golden Paws for Golden Years program ($50 off adopting a dog 7 years and older if you are 60 years and older)?  Yes No

Basic Information

First Name: Last Name:

Email:

Phone (cell): Phone (other):

Best Time to Call:  whenever day night weekend

Street Address:

City: State: ARCOIDILIAKSMNMOMTNDNENMOKSDUTWIWY

If you state of residence is not listed we do not adopt to your state due to distance. We apologize for any inconvenience.

Zip:

Household Information

Who in your household will be responsible for this pet?

List all persons residing in your home. (Include yourself, spouse, friends, children, etc.)
Name, Age, Relationship

Are there plans for (more) children in the future?  Yes No

Is everyone in your household aware of and on board with your intentions to adopt a dog?  Yes No

Living Situation

How long have you lived at this residence?
 < 6 months 6 months - 1 year 1 - 2 years 3 - 5 years  > 5 years

Do you rent or own?  rent own

If you marked "rent," please provide your landlord's name, phone number, and/or email so we can verify that you are allowed to have a dog.

Landlord name:
Landlord phone:
Landlord email:

Type of home:  Ranch Multi-Story Apartment Other
If you said “apartment,” what floor do you live on?

What kind of fence does your yard have?
 No yard/fence Chainlink Wood Plastic Stone/Cement Other

What is the height of the fence?  No fence 3 feet 4 feet 5 feet 6 feet

If you live in a home and do not have a fence, please explain why. Note that MABTR adopts to families in apartments or neighborhoods that do not allow fences but uphold a leash law.

Will your dog have access to the following? (Choose all that apply)
 Doggie door Socialization with other dogs Dog walks outside of home

References

Please provide two personal references we can contact (only one can be a family member):

Reference 1:
Name:
Phone:
Email:

Reference 2:
Name:
Phone:
Email:

Vet Info:
Clinic:
Veterinarian Name:
Phone:

*Please let your references know that we will be calling, so they are not surprised to receive a call from an unknown phone number.

Current Pets

Please list all animals currently living in your household.
Name, Species, Breed, Age

Do you have any pets that aren't altered (spayed/neutered)?  Yes No
If you answered "Yes" to the previous question, please explain why:

Please explain if you have ever lost a pet or had one die from an accident:

Please explain if you have ever given up a pet or put one to sleep:

Please explain if you have ever surrendered a pet to a shelter or rescue:

How much money do you plan to spend on your pet each year? (food, vet, boarding, toys, etc.) $.00

How long will your dog be left alone each day?

Where will your dog sleep?

Where will your dog stay when you are away from home (at work, running errands, etc.)?

Behavior

How do you feel about adopting a dog who needs housetraining? (Note: 53% of MABTR dogs are puppy mill survivors. These dogs are NOT housebroken at the time of adoption but can be after a few months of training.)
 I am willing to work on housetraining. Accidents inside are unacceptable.

Gender preference:  Either  Female  Male

What age range(s) would you be interested in adopting:  <1 1-3 4-7 8+

Please mark the characteristics that interest you:
 Couch potato Energetic Kid friendly Dog friendly Cat friendly Smaller size Larger size Mostly quiet Cuddler Loner Sleeps in dog bed Sleeps in your bed Shy/timid Outgoing Leash trained Potty trained Crate trained Likes car rides

What behavior(s) are you NOT willing to consider?
 Jumps Snores (common) Growls Chews (puppy stage) Timid Plays rough Separation anxiety Barks Digs History of marking Not leash trained

Dogs with medical challenges still make great pets. Would you consider adopting a dog with any of the following:  Separation anxiety Blind  Deaf  Amputee Diabetes

Would you consider adopting a Boston Terrier MIX?  Yes No Maybe

Additional Facts

How did you hear about MidAmerica Boston Terrier Rescue?

Would you be willing to drive part way to meet and pick up your new pet?  Yes No

Additional Comments

Please use the space below to tell us more about yourself. For example, do you have experience with health/behavior issues? How do you discipline and house train your current pets? Is there anything else we should know about you that will help us make a perfect match for you?

Please read and acknowledge the following:

"I declare that all the information contained above is true and correct, that I am over 18 years of age, and that I am a decision-maker in my household. I am looking to adopt a pet, and I will accept full responsibility for his/her care."  I agree

"I will abide by all state and local pet control and leash laws."  I agree

"I give permission to contact the references I've provided."  I agree