MCSR Adoption Form

Please take a few minutes to complete the following questionnaire. Maine Cocker Spaniel Rescue would like the opportunity to help you in your search for a new cocker to welcome into your home.

Maine Cocker Spaniel Rescue’s goal is to place the right dog in the right home. For this we ask that you fill out the following questionnaire. We ask that once you adopt a cocker that you agree to give that cocker at least 2 months to see if it is the right dog for you. These cockers need an adjustment time and sometimes it can take longer even than the two months.

Name _______________________ Tel.________________________ Date______________________

Street________________________ City _______________________ State ______ Zip ___________

Email address: ____________________________________________________________________

Employer __________________________________________ Work Tel. ______________________

Employer (spouse) ___________________________________ Work Tel. ______________________

Referred by ________________________________________________________________________

Why do you want a Cocker? Have you owned one before? ___________________________________

Please list pets you now have in your home: (Note: All dogs in adopter's household must be spayed or neutered.)

Type/Breed Sex Spay/Neut. Age Owned Since Comments

______________________ Yes/ No __________________________________

Please list previously owned pets:

Type/Breed Sex Spay/Neut. Age Dates Owned What happened to him/her?

________________ Yes/ No _______________________________________
________________ Yes/ No _______________________________________

________________ Yes/ No _______________________________________

Do you own ________ or rent ________: a house ________, apartment ________, or condo ________?

If renting, pleasegive landlord's name, address, and telephone number. We require the landlord's written
consent for your having a dog. If possible, please include this consent when you return the application.

Name _________________________________________ Street ____________________________

City ________________________ State _______ Zip __________ Tel. _______________________

Maine Cocker Spaniel Rescue requires that you keep the dog on a leash for six months. This gives the dog time
to get used to its new home. An off leash dog needs to be trained in voice command which will require some obedience training. Although a fenced yard is not a must know that cockers enjoy being outdoors. A free standing kennel can be purchased for this. We do require that an adopted cocker never be tied outside on the end of a lead.

How many adults in your household? _____ children? _____ ages: ____________________________

Do you have much contact with grandchildren or neighborhood/other children? yes _____ no _____

_________________________________________________________________________________

What are the working hours of the adults in the house? _______________________________________

___________________________________________________________________________________

Where will the dog be kept during the day? _________________________________________________

Where will it sleep at night? _____________________________________________________________

Where will it be kept when left alone? _____________________________________________________

Who will be primarily responsible for the care of the dog? _____________________________________

Does anyone in the home have any allergies? yes _____ no ____________________________________

Where and how do you plan to exercise the dog? ____________________________________________

___________________________________________________________________________________

Please describe your lifestyle. Is it active? (e.g., hiking, camping, busy in the community, in and out a lot)
or is it a more relaxed, structured atmosphere?

____________________________________________________________________________________

This dog will be left alone, without human companionship, for about ________ hours per day.

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? ___________________________________________________

________________________________________________________________________________

Would you accept a dog that is older? yes _____ no _____; has been abused? yes _____ no ____

is not reliable with children? yes _____ no _____; has a physical handicap? yes _____ no _____

Knowing that some rescue dogs have had little or no training, are you willing to take the dog to obedience classes?

yes _____ no _____

Are you willing to house train a dog, if necessary? yes _____ no _____

What method have you used in the past? ________________________________________________

________________________________________________________________________________

How would you handle adjustment/training problems such as:

jumping on furniture _______________________________________________________________

jumping on people _________________________________________________________________

barking __________________________________________________________________________

chewing _________________________________________________________________________

Are you willing to give the dog at least two months to adjust to a new environment? yes _____ no _____

Some Cockers need to be professionally groomed (approx. $40) about every two months.

Does this present a problem? yes _____ no ________________________________________________

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? yes _____ no _____

A representative from Maine Cocker Spaniel Rescue will be required to do a home check to meet all
members of the household. When is a good time for this visit?______________________

If you have owned a pet within the past ten years please fill out the following information.

If you now have a pet, when was its last visit to a vet? ________________________________________

What shots has it had in the last year? (Please specify) ________________________________________

___________________________________________________________________________________

Has it been tested for heartworm? yes _____ no _____ When? _________________________________

Is it on heartworm preventative now? yes _____ no _____ If so, what kind? _________________________

MANDATORY:

Your veterinarian is:

Name _______________________________________ Street _________________________________

City ____________________________ State _____ Zip _________

Tel.________________________ (required)

Additional comments:

_________________________________________________________________________________________

Please note that there is an adoption fee of $250 for puppies up to one year of age, $200 for dogs from 1-8 years of age and $75 for dogs 9 years and older. These fees are to help pay for shots, neutering/spaying and boarding fees.

I certify that I am 21 years of age or older and that by adopting a dog from Maine Cocker Spaniel Rescue that I will become the legal owner and be solely responsible for the care housing and well being of the dog. I further understand that at any time I can’t keep the adopted dog then it can and must be turned back over to Maine Cocker Spaniel Rescue.

signed___________________________________________dated________________

Please return completed form to: Maine Cocker Spaniel Rescue

C/O HILL
93 Killick Pond Rd
Hollis Center, ME 04042
Phone: 207-727-3408
OR C/O TEES
PO Box 388
Raymond, ME 04071
207-655-2122