Questionnaire for
Prospective Rescue Adoption Family
Thanks for your interest in becoming an adoptive family as part of the CVBMDC rescue program. In order for an adoption to be successful we need make sure an appropriate match is made taking into consideration the Berner’s needs and adoptive family’s needs. Completion of this questionnaire will assist in our efforts to make sure Berners that come through our rescue program find their way into the most appropriate homes. Please answer the following questions completely and honestly. You will not be rejected as a possible placement solely on the basis of your answers. Please feel free to elaborate on additional pages.
Name: ______________________________________ Date ______________
Occupation: ___________________
Address: ____________________________________
Home Phone: __________________
City/State/Zip: _______________________________
Cell Phone: ____________________
E-mail: _____________________________________
1. Have you ever owned or personally met a Bernese Mountain Dog? Yes ____ No ____
Why do you want a Bernese Mountain Dog?
How did you learn about the breed?
Are you aware of the health problems of Bernese Mountain Dogs?
2. Why do you want a Bernese Mountain Dog from the rescue program rather than from some other source such as a breeder?
3. Have you owned a dog before? Yes ____ No ____
If you have owned a dog(s) in the past, please list breed, age, how long owned, name of breeder, etc.)
Do you currently have any other dogs living with you? If so, please specify breed, age, sex, and whether spayed or neutered.
How do you feel your current dog(s) will accept a new dog?
Have you ever surrendered a dog to a rescue program, pound, shelter, or placed a dog you owned in another home? Yes ____ No ____ If yes, what were the circumstances of the placement(s)?
4. Do you have any other pets? Yes ____ No ____
If yes, please list type of pets.
5. Please describe the characteristics of the ideal dog for you and your family.
6. Do you own or rent your home? Own ____ Rent ____
7. If you rent, is you landlord in agreement with you having a dog on the premises? Yes ____ No ____
8. Please describe the method you will use to restrain a dog on your property. Please include details on size, height, materials, relationship to house, etc.
9. Where will the dog be kept during the day? __________________________________
At night?___________________________________
On average, how many hours will the dog be alone during the day?__________________
10. How many adults in the household? _____ Children? _____
If children, what are their ages? ___________________________
Do all family members want a Bernese mountain dog?
11. What are your plans for care for the dog when you are away overnight or on vacation?
12. Please check any preferences you may have in a dog:
Male ____ Female ____ Puppy ____ Adult ____ Purebred ____ Berner Mix ____
13. Would you be willing to adopt a BMD with special needs, i.e. older, needs surgery, needs medication, blind or deaf? Yes ____ No ____
14. Would you be willing to adopt a BMD requiring special behavior training needs? Yes ___ No ____ If yes, will you have time to attend training classes to achieve a rapport with a Rescue Dog, which will result in a successful placement? Yes ____ No ____
15. What behavior problems do you consider intolerable? (Biting, growling, barking, house soiling, digging, etc.)
16. Are you prepared to spend $150.00 or more a year on heartworm preventative, flea control and annual vaccinations for a BMD? Yes ____ No ____
17. Are you prepared to deal with the cost, which often is more expensive due to the breeds large size, of non-routine/emergency care, especially as the dog gets older? Yes ____ No ____
18. May we visit your home and check references to verify the information you have provided?
Yes _____ No _____
19. For reference purposes, please provide the name, address, and phone number of the veterinarian with whom you are currently established or have used in the past, and a friend or neighbor:
Vet Name/Clinic ________________________________________________________________
Address _______________________________________________________________________
Phone _______________________________________________________________________
Friend /neighbor:
Name______________________________________________________
Address___________________________________________________
Phone______________________________________________________
E-Mail_____________________________________________________
Signature of Applicant Date_________________________
_______________________________________
Signature of Co-Applicant (spouse/partner)
_______________________________________ Date__________________________
After you have completed the above questionnaire,
please email to the two CVBMDC Rescue Coordinators:
Sloane Shepherd sloane8282@hotmail.com
Pat Honchar phonchar@comcast.net
.
We will consider
your email as signature.
WE RESERVE THE RIGHT TO REFUSE / DENY ANY APPLICATION...