CSRNE ONLINE ADOPTION FORM

Available CockersNOTE: CSRNE DOES NOT SHIP DOGS and therefore CSRNE’s cockers are placed only in carefully screened homes within the 6 New England States.

Please take time to read the adoption procedures. We hope it will answer your questions about how CSRNE's adoption process works.

We sincerely hope we can be of service to you. We ask that you fill out this questionnaire completely. It is designed to help you in finding the Cocker Spaniel most compatible with your lifestyle. Our ultimate goal is to match the right dog with the right home for the enduring happiness of both dog and owner. Please complete the entire form and then click the submit button.

Because the rescue cockers are Second Hand Dogs and have not had the benefit of having bonded with their new family since puppyhood and because we usually have no history on whether or not the rescue dogs were socialized around young children, CSRNE has decided that we cannot adopt to families with children under the age of 7 years.   We realize that this policy may rule out some homes that would otherwise be wonderful but our first priority must be the safety of children.

INSTRUCTIONS - PLEASE READ CAREFULLY!

APPLICATIONS WITH PARTIAL INFORMATION WILL NOT BE ACCEPTED. PLEASE HAVE ALL THE NECESSARY DATA BEFORE YOU START THE APPLICATION, YOUR APPLICATION CANNOT BE SAVED AND COMPLETED AT A LATER DATE.

USE THE "TAB" KEY TO MOVE BETWEEN FIELDS.  IF YOU USE THE "ENTER" KEY IN INTERNET EXPLORER THAT IS THE SAME AS USING THE "SUBMIT" BUTTON LOCATED AT THE BOTTOM.

AN ERROR MESSAGE WINDOW MEANS ONE OR MORE FIELDS/BOXES HAVE NOT BEEN FILLED IN OR ARE NOT FILLED IN CORRECTLY.

CLOSE THE ERROR MESSAGE WINDOW AND LOOK OVER THE APPLICATION TO SEE WHERE THE INCOMPLETE OR INCORRECT DATA IS (LETTER INSTEAD OF NUMBER?).  CORRECT THE DATA AND USE THE "SUBMIT" BUTTON.   ALL BOXES MUST BE FILLED IN - SEE BELOW.

PLEASE USE A "0" OR "N/A" WHEN A NUMBER IS REQUIRED AND THE ANSWER IS NOT APPLICABLE.

The form CANNOT be submitted unless all questions are answered and ALL boxes are filled in. If a box is not applicable then "0" or "N/A" must be put into that box. Thank you!
 

ADOPTER INFORMATION
Name
 		Telephone #
Date
Street
 		City
 		State
Zip Code
E-mail
 		Employer
Work Tel.
Employer (Spouse)
 		Work Tel. (Spouse)
Referred by
 		Why do you want a cocker? Have you owned a cocker before?
 		 

Please list cats and dogs you now have in your home: (Note: All dogs and cats in adopter's household must be spayed or neutered). If you do not own any pets, please enter "NA" into each box. If you have fewer than 3 pets put NA in each box for which you have no pet.
Dog1
Name/breed
Sex (M/F or NA)
 		Spay-Neuter (Y/N or NA)
Age
Owned Since
(i.e. 94-present)
Comments
Dog 2
Name/breed
Sex (M/F or NA)
 		Spay-Neuter (Y/N or NA)
Age
 		Owned Since
(i.e. 94-present)
Comments
Dog 3
Name/breed
Sex (M/F or NA)
 		Spay-Neuter (Y/N or NA)
Age
Owned Since
(i.e. 94-present)
Comments
If you have more than 3 dogs, please provide the information requested above in the following area:

Please list previously owned pets: If you have never owned a pet please enter "N/A" into each box.
Dog1
Name/breed
Sex (M/F or NA)
 		Spay-Neuter (Y/N or NA)
Age
Dates Owned
(i.e. 94-01)
What happened to him/her?
PLEASE BE SPECIFIC
Dog 2
Name/breed
Sex (M/F or NA)
 		Spay-Neuter (Y/N or NA)
Age
Dates Owned
(i.e. 94-01)
What happened to him/her?
PLEASE BE SPECIFIC
Dog 3
Name/breed
Sex (M/F or NA)
 		Spay-Neuter (Y/N or NA)
Age
Dates Owned
(i.e. 94-01)
What happened to him/her?
PLEASE BE SPECIFIC
If you have had more than 3 dogs, please provide the information requested above in the following area:

HOUSING INFORMATION
Do you own?
(Y/N) 		Do you rent?
(Y/N or NA) 		Is it a house?
(Y/N)		 Is it an apartment?
(Y/N or NA) 		Is it a condo?
(Y/N or NA)
If renting, please give landlord's name, address, and telephone number. We require the landlord's written consent to your having a dog.
PLEASE USE N/A IF YOU ARE NOT RENTING - ALL BOXES MUST BE FILLED IN
Landlord Name
 		Street
 		City
State
 		Zip Code
 		Telephone #

IMPORTANT: Please read!! CSRNE requires secure barrier fencing if you have children or other dogs. Exceptions to barrier fencing may be made for ADULT ONLY  homes; please enclose a note with your adoption questionnaire describing your environment, life style and how you plan on safely exercising and managing the Rescue Cocker consistent with CSRNE’s Restraint Agreement if you cannot fence.
Do you have a securely fenced yard - 4 enclosed sides?
(Y/N)		 If so, how high?
 		If not, are you willing to fence?
(Y/N or NA)
If not, are you willing to install a pen or run?
(Y/N or NA) 		AND are you willing to leash walk at all times?
(Y/N or NA) 		 

HOUSEHOLD INFORMATION: PLEASE USE A ZERO WHEN A NUMBER IS REQUIRED AND THE ANSWER IS NOT APPLICABLE.
How many adults in your household?
 		How many children?
 		Ages of children
Do you have much contact with grandchildren?
(Y/N or NA) 		Do you have much contact with neighborhood children?
(Y/N or NA) 		What are the working hours of the adults in the house?
Where will the dog be kept during the day?
 		Where will the dog sleep at night?
 		Where will the dog be kept when left alone?
Does anyone in the house have allergies?
 		Who will be primarily responsible for the care of the dog?
 		Where and how do you plan to exercise the dog?
Is your lifestyle active?
 		Is your home a relaxed, structured atmosphere?
 		Please describe your lifestyle
Approximately how many hours a day will this dog be left alone, without human companionship?
 		Please describe the perfect dog for your home. Taking into consideration that Cockers vary greatly in temperament, personality, and activity level, what characteristics do you want in your dog? Please answer in as much detail as possible.
What characteristics are undesirable?

DOG SPECIFIC INFORMATION
Would you accept a dog that is 5 or more years old?
(Y/N)		 Would you accept a dog that has been abused?
(Y/N)		 Would you accept a dog that is not reliable with children?
(Y/N)
Would you accept a dog that has a physical handicap?
(Y/N)		 Knowing that some rescue dogs have had little or no training, are you willing to take the dog to obedience classes?
(Y/N)		 Are you willing to housebreak a dog, if necessary?
(Y/N)
What method of housebreaking have you used in the past?
 		How will you handle adjustment/training problems such as jumping on furniture?
 		How will you handle adjustment/training problems such as jumping on people?
How will you handle adjustment/training problems such as barking?
 		How will you handle adjustment/training problems such as chewing?
 		Are you willing to give the dog at least two months to adjust to a new environment?
(Y/N)

Are you willing to travel up to 2 hours to meet the dog?

(Y/N)

Some Cockers need to be professionally groomed (approx. $35) about every two months. Does this present a problem?


(Y/N)		 The basic needs of a Cocker (feeding, grooming, shots) average $600 to $800 per year. Any special problems could increase this amount. Does this responsibility present a problem?

(Y/N)		 Our adoption process includes a visit by a CSRNE representative to your home to meet all members of your family. When would be the best time?

If you have owned a pet within the past 10 years, this information is MANDATORY.
Enter "N/A" into each box if you have never owned a pet.
If you now own a pet, when was its last visit to a vet?
If you now own a pet, what shots has it had in the last year (Please specify)?
If you now own a pet, has it been tested for heartworm?
If yes, when was it tested for heartworm?
If you now own a pet, is it on heartworm now?
If yes, what kind of heartworm medicine?

Veterinarian Information - MANDATORY INFORMATION - regardless of what state your Vet resides in.  -  Enter "NA" in each box ONLY if you have NEVER owned a pet.
Vet's Name
Vet's Address
City
State: 
Vet's Phone:
Additional Comments:


Escalating kennel and veterinary costs have forced us to raise our adoption fee. I understand there is now an adoption fee of $275.00 for cockers through age 7, to partially defray the costs of boarding and veterinary expenses (spaying/neutering, shots, and heartworm testing) incurred by our nonprofit organization. For cockers 8 years and over, there is a donation of $100 in order to partially defray the costs of boarding and veterinary expenses.

I certify that I am at least 21 years of age and that I will be the legal owner of and, ultimately, solely responsible for the care and well-being of any dog I adopt from Cocker Spaniel Rescue of New England, Inc.

Any misrepresentation of the true facts in this application or in the adoption agreement will invalidate the adoption agreement and will give CSRNE, Inc. the right to reclaim the adopted Cocker Spaniel without refund of the adoption fee. 

Signed
Date

RESTRAINT AGREEMENT

CSRNE, Inc. feels it is important to briefly explain our restraint policy. Cocker spaniels were originally bred as hunting dogs, and many of them retain a strong instinct to air or ground scent. Their nose-activated instincts will easily lead them astray - too often into the path of an oncoming car or a wild animal that could be rabid or into totally unfamiliar territory where they could be lost or stolen - perhaps forever.

CSRNE, Inc. therefore requires that all of its dogs be under restraint at all times when outside. We recognize that not all dog owners are convinced of the need for total restraint. We also realize that this regulation may rule out some homes that would otherwise be wonderful. But we must be firm in our search for a safe environment for the rescue cockers. If you do agree with the above, please sign the following statement and return it with your adoption questionnaire.

I/we agree that any dog adopted from CSRNE, Inc. will be fenced or leash-walked at all times for its own protection from other animals or an unkind passerby. The dog may be put on a tie-out or an outside run in adult only homes and must be supervised by a person who is in the yard with the dog. I understand that refusal to comply with this requirement after having adopted a dog from CSRNE, Inc. will allow CSRNE, Inc. to repossess the dog.

Signed
Signed
Date

Your electronic signature on the Adoption and the Restraint Agreement portions of the form signify you agree to the conditions herein.  (If only one person is adopting then NA should go into the second signature box.)

ATTENTION: PLEASE ALLOW 2 WEEKS FOR US TO RESPOND TO YOUR MAILED OR E-MAILED ADOPTION QUESTIONNAIRE

Be sure to read " About CSRNE's Restraint Policy" .

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CSRNE, Inc.  PO Box 162

   Greenfield, NH 03047    603-547-3363   E-Mail: info@csrne.org

Copyright: 2005, 2006, 2007 Cocker Spaniel Rescue of New England, Inc. All Rights Reserved. 
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 products and services are proprietary marks of Cocker Spaniel Rescue of New England, Inc. .
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