Name ________________________________________________________________________

Address ______________________________________________________________________

City _______________________________ State __________ Zip _______________________

Phone Number _______________________ Fax Number _______________________________

Email _____________________Who referred you to Great Dane Rescue?__________________

Have you had a Great Dane before? If yes, how many and where did you get them? What happened to them? ______________________________________________________________

_____________________________________________________________________________

If no, why do you want a Great Dane? _______________________________________________

_____________________________________________________________________________

Have you had other breeds of dogs? If yes, what were they? _____________________________

______________________________________________________________________________

What happened to them? _________________________________________________________

______________________________________________________________________________

Name of your Veterinarian _______________________________________________________

Address ______________________________________________________________________

Telephone ________________________________

Do you own your home? ______________ How long have you lived there? _________________

If you are a renter, does your rental agreement permit you to keep large dogs? _______________

(We will need a letter from your landlord verifying this)

Do you have a fenced yard? ________ If yes, what kind of fence and how high is it? _________

______________________________________________________________________________

Where will you keep your dog during the day? ________________________________________

at night? ______________________________________________________________________

Is there a family member home during the day? __________If no, how many hours a day will the dog be alone? _______________________

Do you plan to travel with this dog? _____________ If no, where will the dog stay while you are away? ________________________________________________________________________

Who are the members in your household and what are their ages (include yourself) ___________

______________________________________________________________________________

Do young children visit your home on a regular basis? __________________________________

Is anyone in your household disabled, handicapped or have special needs that we should be aware of? _____________________________________________________________________

Does anyone in your household have allergies? _______________________________________

Are other members of your household enthusiastic about adopting a dane? __________________

Who will be primarily responsible for the care of this dog? ______________________________

Do you currently have other pets? Please list them (include ages) _________________________

_____________________________________________________________________________

Are you familiar with the health problems associated with this breed? (short life span, bloat/gastric torsion) _____________________

Are you aware of the cost of food, licensing and regular veterinary care? (one antibiotic treatment can cost as much as $150.00) ______________________

Why did you decide to adopt rather than purchase a puppy? _____________________________

______________________________________________________________________________

I would like to have a dog that is:

an adult _____ (1 to 5) ______ mature (over 5)

I prefer: ____ male ____ female ____ no preference. Color preference? _____________

What is the oldest dog you would consider adopting? ___________________________________

Will you agree to spay/neuter? _____ Will you adopt a dog with special health needs? ________

May we visit your home and check references to verify the information you have provided? ____

I understand that Great Dane Rescue of New England does not warrant the health, temperament or behavior of any dog placed and is not to be held liable for acts of the dog. Great Dane Rescue is primarily a referral service. Final decisions about adoption are made between the parties giving up the dog and the adoptive family. I understand that the fee does not guarantee the placement of a dog in my home. I further understand that if a dog is placed in my home I will be expected to sign a contract with Great Dane Rescue of New England and make an appropriate donation (usually $300.00 to $500.00 depending on age of dog and/or other individual considerations).

Signature ________________________________________ Date ______________________

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