TELL US ABOUT YOURSELF
Your name:
Street address:
City, State & Zipcode:
Home phone:
Cell phone:
Email address:
Age:
Occupation:
SECTION 1: Your Family and Neighbors
Are there any other adults in your household?	YES NO
If YES, please give us their names, ages, occupations and relationship to you
Do they agree with your decision to get a dog?	YES NO
Are there children in your household?	YES NO
If YES, how many children? Please give names, ages and level of experience with dogs
If No, are you planning to have children in the next few years?	YES NO
Will any children in your home be responsible for caring for this dog?	YES NO
Are there a lot of children in your neighborhood?	YES NO
Are you visited by children?	YES, frequently YES, sometimes NO
If YES to either of the above 2 questions, do any of them have access to your yard/kennel/house when you aren't home?	YES NO
If YES, please explain how you intend to prevent them from teasing a dog, letting a dog out either intentionally or by accident, or doing anything else that might be detrimental to the welfare of a dog in your care:
Is anyone in your household allergic to animals?	YES NO
Is anyone in your household afraid of dogs?	YES NO
Is anyone in your household elderly or frail?	YES NO
SECTION 2: Your Experience with Dogs
Have you previously owned a dog(s)?	YES NO
If YES, what breed(s)?
Is this dog(s) still with you?	YES NO
If YES, how many dogs do you currently have and what breed(s)?
Have you previously owned a Leonberger(s)?	YES NO
If YES, is this dog(s) still with you?	YES NO
If NO, what happened to this dog(s)?
How many years did this dog(s) live with you?
If you have never owned a Leonberger, have you seen and/or met one?	YES NO
Have you researched the Leonberger breed?	YES NO
Briefly explain the needs of the Leonberger breed
For each dog you currently own please answer the following: Breed Age Sex Current on all vaccinations? On heartworm preventative? Spayed/neutered? If not, why not? Licensed in your town/county? Temperament, in particular in regard to other dogs
Dog 1:
Dog 2:
Dog 3:
Why have you decided to get a dog or another dog?
Why a Leonberger?
Why a rescue dog?
Have you ever adopted an animal from a shelter or rescue group before?	YES NO
If YES, give name and address of shelter or rescue group as a reference
Have you ever surrendered an animal to a shelter or rescue group?	YES NO
If YES, describe the circumstances
Have you ever been bitten or attacked by a dog?	YES NO
If YES, explain the circumstances
Are you comfortable approaching dogs that you don't know? Please explain
If behavioral problems arose in your dog, how would you deal with them?
Are you familiar with the animal regulations in your area?
Do you know the requirements for obtaining a dog license in your town?
Please give us contact information for THREE people who are knowledgeable about you and your care of dogs. Please include your vet as one of them, and two other people in the dog world (for example, a dog groomer, dog trainer, shelter or rescue person you once adopted from or someone who has dogs all his life and knows you well). WITHOUT REFERENCES WE CAN NOT COMPLETE YOUR EVALUATION.
Reference 1: Name: Phone: Email: Relation to you:
Reference 2: Name: Phone: Email: Relation to you:
Reference 3: Name: Phone: Email: Relation to you:
SECTION 3: Your preferences with the to be adopted dog
What age do you prefer?
What sex?	Female Male No preference
Would you consider a Leonberger mix?	YES NO MAYBE
Would you consider an older dog?	YES NO MAYBE
Would you consider a dog with a health problem?	YES NO
If YES, please explain what health problems you would consider and what health problems you would not
Would you consider a dog that has an emotional or behavioral problem (for example, separation anxiety, shyness, fear aggression, etc.) that might be controlled or cured with training, behavior modification, or the use of drugs?	YES NO
After researching the breed, are there any traits in the breed that you would prefer to avoid? If YES, explain
SECTION 4: Your Environment
Is your neighborhood:	RURAL URBAN SUBURBAN
Do you live in:
Do you own or rent your property?	YES NO
If you rent, do you have permission from your landlord to have a large dog on the property?	YES NO
Do you live in a development or other area where there are a lot of houses nearby?
Do you have neighbors nearby, or do you share a house with other families?
If YES, are they aware that you intend to adopt a large dog?	YES NO
Do you have cats?	YES NO
If YES, are they socialized to dogs?
Do you have other pets or livestock on the property?	YES NO
If YES, please list them
Are there any resctrictions as to the number of dogs and/or combination of dogs and cats that you may have at your residence?	YES NO
How large is your property?
How far is your property located from a busy road?
Do you have a fenced yard or outdoor kennel?	FENCED YARD OUTDOOR KENNEL
If you have a fence, what kind of fence do you have?
How high is the fence?
How large is the area the fence encloses?
Do you have a pool and if so, is the pool independently fenced from the rest of your yard?	YES POOL NO POOL INDEPENDENTLY FENCED NOT INDEPENDENTLY FENCED
Anything else we should know about your home, yard, or neighborhood?
SECTION 5: Your Lifestyle with Regard to a Dog
Are you willing to travel a distance to meet a dog?	YES NO
If YES, how far?
Will the dog live in the house with the family?	YES NO
Is there someone home during the day?	YES NO
If NOT, how many hours will the dog be alone during the day?
If NOT, where will the dog be kept during the day?
At night?
When you go away during the day, where will the dog be kept?
If you go away for an extended period (overnight or longer), where will the dog be left?
Will the dog be allowed to run loose at any time?	YES NO
Is YES, please explain
Are you planning to enroll your dog in an obedience/training class?	YES NO
If NOT, how do you intend to train this dog?
Please describe your previous dog training experiences if you intend to train the adopted dog yourself
How do you intend to exercise this dog?
Please describe the kinds of activities you enjoy sharing with your dog(s)
How much are you willing to spend on vet care for a dog each year?
What do you see as the normal vet care requirements of a dog?
If it is determined that the Leonberger is in need of log term medical care, are you willing to commit the resources to do so?	YES NO
Identify the problems that you feel you are capable of handling in a rescue dog
If a Leonberger were placed with you and you could no longer keep the dog, what would you do with it?
Are you willing to have one of our volunteers come to your house for a home visit?	YES NO
By typing my name in the box below and by submitting this application, I attest that all the information provided is true and accurate. I understand that falsification or fabrication of answers will be grounds to disallow the adoption of a Leonberger from Leonberger Rescue, Inc.
I understand that adoption donations vary. Young puppies are adopted with a spay/neuter contract and a refundable deposit. Refundable deposits may apply in other cases. Adoption donations and refundable deposits are subject to change. I understand that Leonberger Rescue, Inc. has the right to refuse any applicant for any reason.
Applicant's Name
Date
Spouse/Partner's Name
Date

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