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Name:
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Address:
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City, State, Zip
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Email Address:
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Phone:
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Occupation(s):
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Members of household & their ages:
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Current pets, breeds, ages:
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Veterinarian’s name & phone:
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Do you
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Own?
Rent?
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Please check one:
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Apartment
Condo
House
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If renting, please give
landlord’s name & phone:
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Is your yard fenced?
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Yes
No
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If yes, give height & size of area:
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Where will dog live during the day?
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Where will it sleep at
night?
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If outside, describe
shelter:
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Is an adult family member at home during the day?
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If not, please state hours dog will be left alone during the day:
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Have you owned a dog
before?
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If yes, please provide details (breed), how you acquired it,what happened to it:
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Have you crate trained a
dog?
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Have you taken an obedience course with a dog?
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Preference for adoption:
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Male
Female
Either
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age range:
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Would you consider a special needs dog? (examples: one that requires medications, or one that needs obedience training)
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Briefly describe why you’d like to adopt an Irish Red & White Setter as part of your family:
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How did you hear about our Rescue Program?
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By entering my initials here I certify that the above information is true and I understand that, prior to a placement in my home, the above information may be verified. I also agree to a personal interview with a member of the Irish Red and White Setter Association, if requested, to determine the suitability of my home and my ability to care for an Irish Red and White Setter.
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