Adoption Application

Fields Marked with * are required

Contact Information

Name of Applicant (Dog’s Primary Caregiver)*

Co-Applicant (if applicable)

Mailing Address*

Address 2

Street Address (if different from mailing):

City*

State*

ZIP/Postcode *

Primary Phone *

Work Phone

Email *

Family Information

If you have any children under the age of 18, please give their ages:


If you have children under 8, please read our policy.
Do they live with you or visit you?
Live WithVisit
If there are there other occupants in the house, do they share in your desire to adopt a Golden?

YesNo
Does anyone in the household have allergies?*
YesNo
Are the allergies animal related?
YesNo

Dog Preferences

How did you find out about us?*

Have you owned a Golden in the past?*
YesNo
Have you applied to another group for a Golden?*
YesNo
If you have applied to another group, please provide the name and the date of application

May our representative visit you at your home prior to adoption?*
YesNo
Are you willing to consider a dog with special needs?*
YesNo
A dog that is deaf or blind?
YesNo
What age dog are you interested in adopting?*
0-6 Years7-8 Years9+ yearsAny Age
What activity level would you prefer?*
HighMediumLow
Would you consider adopting a Golden mix or x-breed?*
YesNo
Sexual Preference*
MaleFemaleDoesn't Matter

Pet Care Questions

How long have you lived at your current address?*

Do you own or rent?*
OwnRent

(If you rent, please provide your landlord’s name, address, and phone number)

Do you have your landlord’s permission to have a large dog at your residence?
YesNoN/A
Please identify all veterinarians used over the past five years (including name, address, and phone number)*

Please list all the pets you have owned in the past three years and include: species, sex of pet, whether spayed or neutered, if not altered, please explain:

Are these pet(s) still alive?

YesNo
Have any of your pets ever been treated for heartworm?
YesNo
If yes, please explain the circumstances

Please list two references including their names, addresses, and phone numbers (Only one can be a relative. You cannot use a vet as a personal reference.)*

We reserve the right to call your landlord (if one is renting). May we have your permission to check your veterinarian and personal references?*
YesNo
If yes, please notify your veterinarian that we may call and that you give your permission for us to check on the past care of your animals
Are you familiar with the use of a dog crate to train and/or confine the dog in your absence or at night?*
YesNo
Are you willing to use a crate (if needed)?*
YesNo
How long will your dog be left along during the day?*

Where will the dog be kept during the day?*

Where will the dog be kept during the night?*

Is there anyone home during the day?*
YesNo
Is your yard fenced?*
YesNo
If fenced, type and height of fencing?

What is the size of the dog’s yard area?

Will the dog be walked daily?*
YesNo
Allowed to run free off your property?*
YesNo
Will your dog be in the house?*
YesNo
Will your dog have the run of the house?*
YesNo
Be tied outside?*
YesNo
Live in the yard?*
YesNo
Will your dog receive formal obedience training?*
YesNo
Have you ever trained a dog before?*
YesNo
Are you aware that Goldens shed all year long?*
YesNo
Are you aware that routine costs of maintaining a dog can easily average $1000.00 per year?*
YesNo
Will you groom your Golden or use a groomer?*
SelfGroomer
In the event you are unable to care for this pet in the future, who will accept responsibility for its care for the balance of its life?*

Will you notify a golden rescue organization if this should occur?*
YesNo
Have you sold, given away, or surrendered a pet to a shelter or rescue in the past?*
YesNo
If yes, please give an explanation:

Please tell us why you want a Golden Retriever?*

What type of activities will your dog and you enjoy together?*

If you move, what will you do with the dog?*

Are you willing to take responsibility of this dog for 10 years or more of its life?*
YesNo
Have you read our Adoption Procedure?*
YesNo
Have you read our contract?
YesNo

Important: If you get an error when submitting this form, please email us at info@heartlandgoldenrescue.org, as there is a chance that the form was recorded in the database and we can pull it from there.