Dog Adoption Survey

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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How many hours do you spend at work away from home? *

0 hours

1 - 16 hours

17 - 32 hours

33 - 40 hours

40+ hours

Are you currently a full time or part time student? *

Yes

No

How did you find out about the Babinski Foundation?

Radio Advertisements

Print Advertisements

Social Media

Google

Billboard

Sunset Cinema

Do you rent or own your home? *

Rent

Own

Type of Home: *

House

Apartment

Trailer

Other

Landlord's Phone Number

(###)

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Do you have a fenced in yard? *

Yes

No

Fence type:

Wood Fence

Chain Fence

Underground

Will the dog be kept inside or outside? *

Inside

Outside

Where will the pet stay when home alone? *

Pet Crate

Free Range in House

Gated Area

In Yard

Doggy Daycare

With Friends and Family

Do you currently have a veterinarian? *

Yes

No

Veterinarian's Phone Number

(###)

###

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Would you tolerate potty accidents in the home? *

Yes

No

Are you able and willing to afford expenses for this pet, including proper nutrition, routine veterinary exams, vaccines, and unexpected veterinary bills? *

Yes

No

What traits would you not tolerate with your new dog? *

Aggression

Barking

Destructive Chewing

Digging

Dominance with Other Animals

Jumping

Nervous

Not Crate Trained

Not Good with Children

Stubborn

Hyper

A dog's life is typically 10+ years. Are you willing to take responsibility for this animal for that length of time? *

Yes

No

Please list 3 personal references, aside from your veterinarian, that we have permission to call in regards to this potential adoption. *

Yes

No

Reference #1 Phone Number *

(###)

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Reference #2 Phone Number *

(###)

###

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Reference #3 Phone Number *

(###)

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