P.O. Box 17464
Urbana, IL 61803

Your answers on this questionnaire will help us to match your needs with the German Shepherd Dogs in our program. If we do not currently house a German Shepherd Dog that you would like to own, please notify us if you would like to remain on a waiting list for future puppies or adults.


NAME ____________________________

ADDRESS ____________________________________

____________________________________

CITY ________________ STATE ______ ZIP CODE __________

PHONE DAY ( ) ______________ NIGHT ( ) ______________

EMPLOYER _____________________ how long? _________________

EMPLOYER _____________________ how long? _________________

Please list two personal references:

Name ___________________________ Phone ( ) ____________

Name ___________________________ Phone ( ) ____________

Please list a veterinary reference: (If you have, or have had other animals)

Name ___________________________ Phone ( ) ____________

Clinic Address _________________________________________

Do you prefer a male dog, or a female dog?


Do you have a preference for the color of your German Shepherd Dog? Check all that apply.

___ Black/Tan

___ Sable

___ Black/Silver

___ Solid Black

___ Black/Red

___ Solid White

___ Black/Tan Saddle Back

___ No Preference


Do you have a preference for the age of you German Shepherd Dog? Check all that apply.

__ under a year

__ over 5 years

__ 1-3 years

__Senior Citizen* (7 years & up)

__ 3-5 years

__ No preference

*those considering a senior citizen may qualify for medical care financial aid, please ask if interested

Who is this German Shepherd for?

Who will have primary responsibility for the dog's care?

Does anyone in your family have allergies to dogs?
___ yes ___ no

Have you considered the long term commitment of time and financial resources required for dog ownership?
___ yes ___ no

Have you and your family discussed the pros and cons of owning a German Shepherd Dog?
___ yes ___ no

Is everyone in your family enthusiastic about getting a German Shepherd Dog?
___ yes ___ no

Have you owned a German Shepherd or any dog before?
___ yes ___ no (If yes, provide a brief history)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

What is it about a German Shepherd Dog that interests you?

_____________________________________________________________________________

_____________________________________________________________________________

What other breeds have you considered?

______________________________________________________________________________________

What are the most important characteristics that you would like to see in a German Shepherd?

___ Active

___ Calm

___ Playful

___ Intelligent

___ Loving

____ Protective

___ Dominant

___ Submissive

___ Independant

___ Other: ____________________
Note: Aggressive and severely problematic behavior animals are not put up for adoption, if they demonstrate any of these behaviors while in our care.

To facilitate the bonding process, obedience training is highly recommended. Would you like to have lessons with your new dog?
___ yes ___ no

How do you plan to discipline the dog?

_____________________________________________________________________________

_____________________________________________________________________________

Which of the following best describes your current residence?

___ Own House

___ Rent Apartment

___ Rent/Lease House

___ Own/Lease Mobile Home

___ Own/Lease Townhouse

  

___ Own Land: (cirlcle one)
In Mobile Home Park Rural Farm In Town Other (explain)
Note: If you rent or lease your residence, or live in a Park, proof of permission to have LARGE dogs will be required before adoption is finalized. Please provide photocopy of lease if possible.

Do you have a fenced yard? ___ yes ___ no
Type: _______ Height: ______ # of Gates: ____
Can children easily open the gates? ___ yes ___ no

If your yard is not fenced, do you have a secure dog run?
___ yes ___ no

What improvements, if necessary, will you make to secure your yard?

_____________________________________________________________________________

_____________________________________________________________________________

If you do not have access to a fenced area at your home, how do you plan to exercise your dog and allow your dog to eliminate?

_____________________________________________________________________________

Have you checked your yard for dangerous articles, plants, or anything the dog could use to climb and/or jump the fence (i.e.. Dog House, Picnic Table), or dig under the fence?
___ yes ___ no

If you have a pool, is it fenced?
___ yes ___ no

Do strangers (Meter Readers, etc.) require access to the area your dog will occupy?
___ yes ___ no

Do friends, relatives and children have access to your home, property and/or car without your supervision?
___ yes ___ no

Are you willing to instruct your children and other people that visit your home on the proper handling and care of German Shepherd Dogs?
___ yes ___ no

Are there any distractions outside the yard that may disturb and/or upset your dog? (Neighbor's dog, loose dogs on the street, neighborhood children)
___ yes ___ no

Approximately how many hours each day will your dog be alone? (circle one)
3 hours or less 3 - 6 hours    6 - 12 hours   12 -18 hours    longer than 18 hours

      

How long will your dog be confined when left alone at home?

Do you travel out of town? If so, how will the dog be cared for during your absence?

_____________________________________________________________________________

Are you gone often? ______________ Would you consider taking the dog with you? __________

Will the dog be kept primarily indoors or outdoors?

Where will the dog sleep at night?

What other animals currently live in/at your home? (continue your list on the back of this sheet, if necessary)

Type of Pet

Sex/Age Fixed?

How long owned?

Kept where?
     


     



How many people live in your home? (continue your list on the back of this sheet, if necessary)

Name

Relation to you

Age (of children)


   


   


   


   


   



How did you hear about our organization?

___ Veterinarian (Name):______________

___ Petsmart/Luv-a-pet Center

___ Shelter (Name): __________________

___ Flyer

___ Newspaper (Name): _______________

___ TV

___ Friend

___ Radio

___ A previous adopter of a dog from our organization: ___________

 

Would you consider volunteering for our organization? ___ yes ___ no

If yes, in which area?

___ Animal Caretaker

___ Accountant/Bookkeeping

___ Temporary Home Provider

___ Party Planner

___ Transportation of Animals

___ Play Specialist/Dog Walker

___ Telephone Calling

___ Obedience Buddy

___ Computer Assistance

___ Financial Sponsor

___ Fundraising/Donation Representative

___ Other _______________________



Signature: __________________________________ Date: ___________________

Thank you for taking the time to complete this questionnaire. You answers will permit us to more effectively match your needs with dogs in our program.

If you have any comments or concerns about adopting a rescue German Shepherd Dog or about this program and its mission, please use an extra page to share them with us. We are always interested and open to your viewpoint.

We do reserve the right to refuse any adoption.

CI GSD Rescue is a registered, incorporated, Not For Profit Organization in the State of Illinois. All Donations are tax-deductible.