Today's Date

MM

DD

YYYY

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Work Phone

(###)

###

####

Do you often have other people visiting your home?

Yes

No

Grandchildren?

Yes

No

Other children?

Yes

No

Is everyone in the residence and family agreeable to adopting a dachshund?

Yes

No

Have your children (if applicable) been exposed to dachshunds?

Yes

No

Not Applicable

Are you willing to teach everyone in your home, and all visitors, the proper care and treatment of a dachshund?

Yes

No

Are you willing to teach young children the proper care and treatment of a dachshund?

Yes

No

Are you willing to always monitor young children with the dachshund?

Yes

No

Even a dachshund that has proven reliable with young children?

Yes

No

Read books about dachshunds, and discuss the dachshund breed with your veterinarian, animal behaviorists, and other professionals in order to better understand the dachshund breed and their special characteristics?

Yes

No

Take the dog to a veterinarian at least once a year for a physical exam, shots, and heartworm check?

Yes

No

Take the dog to a veterinarian when ill?

Yes

No

Welcome the dog into your family as a permanent member?

Yes

No

Return the dog ONLY to Dena Delgado and Southern California Dachshund Rescue if you decide that he/she cannot be a member of you family?

Yes

No

Maintain heartworm preventative medications throughout the dog's life?

Yes

No

Do everything within your power, and with the help of your veterinarian, and/or other professionals to ensure that the dog has a long, healthy life?

Yes

No

Financial obligations of responsible pet ownership?

Yes

No

Special needs and time and patience involved with rescue dachshunds?

Yes

No

Have you ever owned a dog?

Yes

No

Have you ever owned a DACHSHUND?

Yes

No

Do you currently own any other pets?

Yes

No

Have ALL of the animals listed above (if any) been spayed or neutered?

Yes

No

Are you familiar with the unique personality of a dachshund?

Yes

No

Are you aware that purebred dachshunds can have a predisposition to back problems, weight gain, and house training problems?

Yes

No

Are you aware that purebred dachshunds sometimes are not the best choice for families with very young children?

Yes

No

Abused?

Yes

No

Not reliable with children?

Yes

No

Physically handicapped?

Yes

No

Requires ongoing medication other than heartworm preventative?

Yes

No

Requires continued house training?

Yes

No

Older?

Yes

No

If you checked yes above, what age are you willing to consider?:

Over 10 years

7 to 10 years

5 to 7 years

Would you consider adopting a pair of dachshunds in the case of dogs that should not be separated and need to be placed together?

Yes

No

Type of residence:

House

Condominium

Apartment

Own or Rent?

Own

Rent

If renting, is landlord agreeable to you having a rescued dachshund?

Yes

No

Not Applicable

Do you have a yard?

Yes

No

Fenced?

Yes

No

Not Applicable

If not fenced, do you have an exercise program for the dog?

Yes

No

Not Applicable

Do you have a swimming pool or spa?

Yes

No

If yes, is it safety fenced?

Yes

No

Not Applicable

If not safety fenced, do you have a pool alarm system?

Yes

No

Not Applicable

Are there stairs in your residence?

Yes

No

Would you be willing to take the dog for obedience training if needed?

Yes

No

Are you familiar with the necessary shots (annual) as well as heartworm testing and preventative?

Yes

No

Are you familiar with flea/tick treatment and prevention?

Yes

No

Color:

Red

Black and Tan

Other

No Preference

Coat:

Smooth

Long

Wire

No Preference

Size:

Standard (18 lbs and over at 12 months of age)

Miniature (11 lbs and under at 12 months of age)

"Tweenie" (that unrecognized size between 11 and 18 lbs)

No Preference

Gender:

Male

Female

No Preference

Have you read and understand our adoption and rescue policies?

Yes

No