Adopter Information Form Please copy this text into an email, complete the form and email it to: adopt@miniaussierescue.org or your local MARS Area Coordinator (see our website for addresses) Thank you….. for your interest in sharing your life with a rescued Miniature Australian Shepherd. We at MARS believe that every dog deserves a safe, loving forever home, so we hope that you will understand the time and care we take in matching our dogs with just the right family. The responses on the Adopter Information Form provide us with the framework for placing a MARS dog. Please respond truthfully, answering all questions asked. There are no wrong answers, unless you refuse to agree with any of our conditions of adoption. We just want what is best for each dog in our care. Personal Information Name: ______________________________________________________________ Age: __________ Address: ____________________________________________________________________________ City, State, Zip: _______________________________________________________________________ Home Phone: _________________________ Cell Phone: ____________________________________ Email: ______________________________________________ What is the best way for us to contact you? ____ Phone ____ Email Describe yourself – your energy level, your interests, your favorite activities, etc. Describe your ideal dog – its energy level, personality, level of training and special skills, etc. Because MARS dogs often have special needs, please tell us what types of behaviors, medical conditions, etc. you could, and could not, live with in an adopted rescue dog. Would you consider adopting a blind or deaf Mini Aussie? How much do you anticipate spending each year for the care of your dog? (Food, veterinary care, training, boarding, toys, etc.) $ ____________ Personal References Please provide us the names of two individuals (do not include family members) who are familiar with your experience as a pet owner. (Please obtain their permission before listing them here.) Name: __________________________________________ Relationship:________________________ Phone – Day: _____________________ Evening: ___________________ Best Time to Call: _______ Email:_________________________________________________ Name: __________________________________________ Relationship:________________________ Phone – Day: _____________________ Evening: ___________________ Best Time to Call: _______ Email:_________________________________________________ Your Home and Yard Your home is a: House ____ Condo/Co-op ____ Apartment ____ Mobile Home _____ With a yard _____ Without a yard _____ How long have you lived in this home? ___________ If less than one year, please provide your previous address and length of time you lived there. __________________________________________ ____________________________________________________________________________ Describe the neighborhood – is it on a busy street or in a rural setting? Do you ____ Own or ____ Rent your home? If you rent, you must provide written consent from your landlord to bring animals onto the property. Please provide the following, and attach a letter of consent to this application. Landlord’s Name: _____________________________________________________________________ Phone: _________________________ Do you have any neighborhood restrictions/homeowner’s association rules which might preclude your ability to have a dog in your home? ____ Yes ____ No Do you have a fenced yard or fenced in area for the dog to use? ____ Yes ____ No If yes, what type of fencing? _________________________________ Is it attached to your house and accessible from a door? ____ Yes ____ No Height of Fence: ____________ What is the approximate size of your fenced area? ___________________ If you do not have a fenced yard, how do you plan to exercise the dog? __________________________ ________________________ And where do you plan for the dog to go to eliminate? _______________ Your Family and Extended Family How many adults live in your home? __________ Name M/F Occupation _____________________________________ _____ ____________________________________ _____________________________________ _____ ____________________________________ _____________________________________ _____ ____________________________________ _____________________________________ _____ ____________________________________ How many children are in your immediate family and live in the home? __________ Name M/F Age Activities _____________________________________ _____ _______ ___________________________ _____________________________________ _____ _______ ___________________________ _____________________________________ _____ _______ ___________________________ Is everyone in the family in agreement with the idea of adopting a Miniature Australian Shepherd? ____ Yes ____ No - Explain _________________________________________________________ Are there regular visitors to your home (human or animal) with whom your new dog must get along? Name Relationship Age M/F Frequency of Contact _______________________________ _______________ _____ _____ ____________________ _______________________________ _______________ _____ _____ ____________________ _______________________________ _______________ _____ _____ ____________________ _______________________________ _______________ _____ _____ ____________________ _______________________________ _______________ _____ _____ ____________________ _______________________________ _______________ _____ _____ ____________________ _______________________________ _______________ _____ _____ ____________________ _______________________________ _______________ _____ _____ ____________________ _______________________________ _______________ _____ _____ ____________________ Please identify any of these people who might have difficulties interacting with the dog and for what reason: Have you, or anyone in your extended family or friends, owned a Miniature Australian Shepherd or Australian Shepherd? If so, what did you like the most about the dog(s)? The least? Your Pets and Activities Do you currently own another pet or pets? If so, list type of animals, breed, names, ages and sex (neutered or not). Dog/Cat/Other Breed Name Age M/F-N? ________________ ________________________ ________________________ ______ _____ ________________ ________________________ ________________________ ______ _____ ________________ ________________________ ________________________ ______ _____ ________________ ________________________ ________________________ ______ _____ ________________ ________________________ ________________________ ______ _____ What types of activities do you participate in, or plan to, with your dog? (Check all that apply.) ____ Conformation ____ Obedience ____ Agility ____ Frisbee ____ Herding ____ Therapy ____ Jogging ____ Walking Other _________________________________ Do you now, or plan to, compete? ___ Yes ___ No Do you now, or plan to, train regularly? ____ Yes ____ Hours a week ____ No Where do you, or will you, train or find training advice? What is your preferred training style? Please list the names of all pets that you have owned in the last 10 years and the reason they are no longer living with you. Dog/Cat/Other Breed Years Owned Reason ________________ ________________________ ___________ __________________________ ________________ ________________________ ___________ __________________________ ________________ ________________________ ___________ __________________________ ________________ ________________________ ___________ __________________________ ________________ ________________________ ___________ __________________________ ________________ ________________________ ___________ __________________________ ________________ ________________________ ___________ __________________________ Do you have a regular veterinarian? ____ Yes ____ No If you have owned pets in the last 10 years and do not have a regular veterinarian, please explain ________________________________________ ____________________________________________________________________________________ Your Current, or Future, Veterinarian’s Name: _______________________________________________ Address: ____________________________________________________________________________ Phone: _____________________________________ Fax: __________________________________ Your Living Arrangements If you adopt a dog, where will s/he spend the day? ____ Loose indoors ____ Crate _____ Basement ____ Garage ____ Fenced Yard ____ Kennel ____ Doggy DayCare ____ w/Relatives Other:_____________________________________________________________ On average, how many hours will the dog spend alone, i.e., without human company, each day? _______ Where will dog spend the night ___ Loose indoors ____ Crate ____ Basement ____ Garage ____ Fenced Yard ____ Kennel Other:_________________________________________________ Conditions of Adoption In order to protect our dogs, we need you to agree to some basic conditions of adoption. Please initial your understanding of each item listed below. If you have questions or concerns, please contact a MARS representative for further explanation: You understand that MARS requires all adopted dogs to be spayed or neutered. ________ You understand that if you adopt a MARS dog, you are required to license the dog and provide regular and preventative veterinary care. _______ You agree to a pre-adoption home visit and agree to allow MARS representatives post-adoption access to your home and the dog. ________ You agree to contact MARS and return the dog to MARS should your interest in the dog or your circumstances change where you cannot keep the dog. ________ Mini Aussie Rescue & Support How did you hear of Mini Aussie Rescue & Support? MARS does request an adoption fee, which helps us cover some of the expenses incurred in rescue and rehabilitation of Miniature Australian Shepherds in need. Anything received above that amount is a tax-deductible donation, and is greatly appreciated. Please note that we do reserve the right to refuse to adopt a MARS dog to any individual for any reason whatsoever. By signing this document, either physically or by entering my name electronically in the line below, I authorize MARS, Inc. to contact my listed references and my veterinarian to discuss my pet owning and keeping abilities, and to share that information with other rescues and shelters. By signing, I state that I have never been arrested for, or convicted of, animal abuse or neglect. ________________________________________________________ ___________________ (Signature) (Date) Please be aware that, due to a mutated gene called MRD1, many herding dogs, including Miniature Australian Shepherds, are sensitive to one of the most frequently used heartworm preventatives, ivermectin. Ivermectin is used in commonly prescribed heartworm preventatives and should be avoided, unless your dog has been tested for the mutation. Please visit www.busteralert.org for information about ivermectin, testing your dog for the MDR1 mutation and other drugs to avoid. Miniature Australian Shepherds are also known to be sensitive to the vaccine for Leptospirosis, commonly administered by veterinarians in a “7-way” or “5-way” inoculation. This vaccine, and the vaccine for Lyme disease, should be avoided as serious health problems can result. Mini Aussie Rescue & Support, Inc. (MARS) PO Box 636 Hillsboro, NH 03244