BlueMoon Meadows - A Caring Place for Orphaned Pets


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Thank you!

Your Contact Information

Date: (mm/dd/yy )
Name(s) (both names if a joint application):
Street Address:
(Apt. #): City
State : Zip:
Home Phone plus Area Code (xxx-xxx-xxxx)
Work Phone plus Area Code (xxx-xxx-xxxx) Cell Phone with Area Code
Driver's License Number:
Name(s) Pet(s)You are Interested In Adopting:

Privacy Note: The requested information is for the private use of BlueMoon Meadows and will never be made public.


1) Have you ever owned a dog before?

(Additional dogs can be listed in question #5 below)

Do you still have that dog?

If yes, list dogs name, breed, age & sex



Age : Male Female

Spayed/Neutered? YES NO

If no, please explain

2) What happened to your last dog?

3) Please answer the following questions, during the last five years:

a) Have you lost a pet (not through death)?


b) Have you had one poisoned?


c) Have you had an animal killed by a vehicle?


d) Have you had an animal die due to disease?


If yes, what did the animal die of?

IF you answer YES to any of the questions in #3 - Please explain.

4) For what purpose do you want this dog?
5) Do you have any other animals?
If yes, please list below

Name- Type of Pet

Male Female
Male Female
Male Female
Male Female
Male Female

Are all pets spayed/neutered?


Due to the many health benefits accruing from spaying and neutering, as well as to prevent accidental litters, we require that all resident pets must be neutered/spayed.

6)  Do you have children at home? YES NO If yes, please list below

Child Name

Age Sex
Boy Girl
Boy Girl
Boy Girl
Boy Girl
Boy Girl

7) Do you live in a house? (if NO, check dwelling)





8) Do you Rent? or Own?

9.) If you rent, do you have the landlord's written permission to keep a dog and proof of pet deposit where required? YES NO
A copy of the landlord's permission will be required or we will not do the home visit or adoption without it, nor will we contact landlords to secure these documents.

10) Do you have a fenced in yard?   YES NO What type of fencing? Height?

If you have a doggy door, does it open only into the fenced yard?


If you live in an apartment/town home, is there a safe place to walk/exercise the dog?

11) Is someone home during the day? YES NO

If no, please explain

12) What provisions will be made for your dog if nobody is home during the day?

Loose inside?

In crate?

In fenced yard?


13) Do you intend to keep this dog primarily:



Where will the dog sleep?
14) Do you have a sex preference? Male Female No Preference 15) Do you have a color preference? YES NO


16)What age range would you prefer?

Would you consider an older dog?

YES NO If yes, to what age?
17) Are other members of your household aware that you are considering adopting a pet? YES NO Does everyone in your home want this dog? YES NO

18) Are you prepared to assume the financial responsibilities of caring for an animal, including inoculations, heartworm preventative, veterinarian care, good quality food, licensing, etc.? YES NO

Name, Address and phone number of your Veterinarian:

Vet /Clinic Name

Vet/Clinic Address

Phone Number

Please let your clinic know we will be calling so they can release information to us.

In order for the application to be considered, the veterinary records for current resident pets must be complete and up to date; all resident dogs and cats must be vaccinated, and dogs must be on heartworm preventative. There are no exceptions to this requirement.

19) Do you understand that the dog you adopt must be kept on monthly heartworm and flea preventative? YES NO

20) Are you planning to move in the near future? YES NO

If yes, please explain.

If yes, are you willing to give BlueMoon  the new address? YES NO

21) Is anyone in your house allergic to animals? YES NO

If yes, please explain how the allergy is treated if you are bringing in a dog.

22) Are you familiar with the animal control regulations in your area? YES NO
23) What circumstances, in your mind, justify giving up a dog?

24) Are you willing to allow a BlueMoon Meadows representative to visit your home by appointment? YES NO

25) Please provide three references other than your veterinarian (Examples: groomers, dog trainers, rescue organizations, other pet owners.).
Name Phone

26.) How did you hear about BlueMoon Meadows Inc.

Internet Search


Vet, Clinic, Pet Store, or Shelter Referral


Dog/Obedience Club

Transporting pets

Another Rescue Group


Hospital or Health Care Provider


27.) Do you accept that to defray our program expenses for rehabilitating your dog and to help the next rescue there will be a donation payable immediately by check, cash, or money order upon adoption and delivery of the adopted dog? YES NO
28.) Do you accept that the adopted dog may not be transferred to another party and that if the dog must be given up for any reason, he or she is returned to BlueMoon Meadows? YES NO

Additional Comments
I have read and am in full agreement with the BlueMoon Meadows Inc. Terms of Adoption. By clicking on the submit icon below, I am attesting to the truthfulness of my answers. I agree the adopted dog shall not be kept exclusively outside, will be on regular heartworm and flea preventive for life, and will receive good nutrition, all vaccinations, and normal health care. I understand that falsification of any of the above information will be grounds to disallow the adoption. I further understand that BlueMoon Meadows, Inc. will always be interested in our adopted dogs and may at any time inquire about the welfare of the adopted dog during the life of my dog. I will also provide the coordinators with new e-mail addresses and changed home addresses and phone numbers as they occur, as well as annual updates on how my dog is doing in his/her new home.




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