Adoption Application

Start your Col. Potter Cairn Rescue Network (CPCRN) adoption journey by completing the Adoption Application below and taking the first step toward welcoming a new best friend into your life.

ATTENTION POTENTIAL ADOPTERS PLEASE TAKE NOTE OF OUR AGE POLICY:

We have had to implement this age policy due to the large portion of older/disabled (needing a lot of medical attention) dogs returned/newly surrendered to us. Because an owner has either passed away or gone into an assisted living situation and the family is not able/willing to take on the responsibility for the dog, many of our previously adopted dogs are coming back. We have extreme difficulty in finding these dogs a new forever home.

If your age is 21 – 67 years old, you are eligible to adopt the following:
- Puppy, Youngster (1-3), Teenager (4-7), Mature (8-10), or Senior (11+).

If your age is 68 – 77 years old, you are eligible to adopt the following:
- Teenager (4-7), Mature (8-10), or Senior (11+). Your application will NOT be accepted if you select Puppy or Youngster (1-3).

If your age is 78 years old or older, you are eligible to adopt the following:
- Mature (8-10) or Senior (11+). Your application will NOT be accepted if you select Puppy, Youngster (1-3), or Teenager (4-7).

Policy Agreement

Before filling out the application, please read the Adoption Policies & Procedures.

Do you agree to keep the dog licensed with appropriate information at all times?(Required)

Yes

Do you agree to comply all City, Country, State and Federal rules as they pertain to dog ownership?(Required)

Yes

Do you agree to contact Col. Potter Cairn Rescue (CPCRN) if you can no longer keep this dog?(Required)

Yes

Are you willing to provide a crate for your rescue dog to help during the transition period?(Required)

Yes

Do you agree to allow a rescue representative or a CPCRN Volunteer to visit your home by appointment to do a "safety" inspection?(Required)

Yes

If you answered No, to any of the above questions, please state your reason for declining:

Do you plan on using electric (hidden/underground) fencing as the primary means of containment?(Required)

We do not adopt our Rescue Terriers to anyone with electric fencing as their primary means of containment.

Yes

At the time you adopt one of our rescue dogs, you will be asked to make a donation to CPCRN. This donation helps defray shelter fees and other costs paid to procure our Rescues, the cost of transporting them to our foster homes, the costs of providing them with food and appropriate veterinary care, including spay/neuter, immunizations, heartworm testing and prevention, and other medical and/or grooming needs as are required by the particular dogs in our program. As adoption donations do not constitute purchase monies paid for the Rescue, they are not refundable in the event that you decide to return the Rescue or for any other reason.

Are you able and willing to make a Rescue Adoption donation if you adopt a rescue dog through Col. Potter Cairn Rescue?(Required)

Yes

Adoption Applications require four personal references.

Are you able to provide four personal references?(Required)

Yes

General Information

Name of Person Filling out the Form(Required)

First Last

Are you the applicant?(Required)

Yes

Indicate why you are filling out this application for another party(Required)

Not Applicable

Applicant does not have a computer

Applicant submitted a hand-written application for transfer

Telephone Application was taken

Applicant Name(Required)

First Last

Applicant Age(Required)

Co-Applicant Name

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

We cannot accept any application from a Canadian home at this time unless the adoptive home has a clear ground transport plan to move the dog across the border by coming into the US to pick up.

Do you own a second home?

Yes

Second Home Address

Street Address Address Line 2 City State ZIP Code

In what type of home is your second address?(Required)

Does your second address have a yard?(Required)

Yes

Is the yard fenced in?(Required)

Traditional fence, not electric

Yes

Email(Required)

Primary Phone(Required)

Work Phone

Cell Phone

Indicate the best time for CPCRN Volunteer to call you(Required)

Previous Applications or Adoptions

List any other Rescue(s) and/or Shelter(s) from which you have recently applied for adoption; If none please enter n/a(Required)

Have you ever applied to adopt from CPCRN before?(Required)

Yes

When did you last apply to/adopt from CPCRN?

Did you adopt a dog previously from CPCRN?(Required)

Yes

What year did you adopt a dog?(Required)

What was the Col. Potter dog's name you adopted?(Required)

Household Information

Does everyone in the household know that you are applying for a rescue dog and do they all agree?(Required)

Yes

Please Explain(Required)

List of ADULT FAMILY members currently residing in the household, INCLUDING YOURSELF(Required)

Click on the + sign to add additional rows

Name

Age

Occupation

Do any ADULT NON-FAMILY members currently reside in the household?(Required)

Yes

List of ADULT NON-FAMILY members currently residing in the household(Required)

Click on the + sign to add additional rows

Name

Age

Relationship

Do any children under 18 years of age reside in the household?(Required)

Yes

List of CHILDREN UNDER THE AGE OF 18 residing in the home(Required)

Click on the + sign to add additional rows

Name

Age

Relationship

Do any children under 18 years of age VISIT FREQUENTLY?(Required)

Yes

Please list any children under 18 years of age who VISIT FREQUENTLY(Required)

Click on the + sign to add additional rows

Name

Age

Relationship

Frequency

Typical Duration

Matchmaking Information

List the hobbies/activities in which you and your family participate(Required)

What energy level would you prefer your dog to have?(Required)

Mellow

Sofa-buddy

Energetic

Somewhere in between

Do any members of your household have allergies?(Required)

Yes

List the members and describe the reaction to animals(Required)

For whom are you adopting the dog?(Required)

Select all that apply

Myself

My Spouse

My Child

Other

Why do you want to adopt a dog?(Required)

Why did you choose rescue?(Required)

What specific characteristics are you looking for in your future rescue dog?(Required)

For example, playmate for resident pet(s), companionship for you, good fetching ability, potential agility or earthdog candidate, etc.

What is the ONE most important factor you are seeking in a dog?(Required)

Are there any specific issues you absolutely cannot tolerate in your rescue dog?(Required)

For example, inappropriate barking, housebreaking, etc.

Many of our rescues come with "baggage". How do you plan to work through this?(Required)

How long do you feel is the appropriate time needed to work through issues with your rescue dog?(Required)

What research, if any, have you done on the Terrier breed to ensure they are the desired breed?(Required)

Current Pets

Do you currently have any pets in your home?(Required)

Yes

List all CURRENT pets(Required)

Click on the + sign to add additional rows for each pet

Name

Species / Breed

Age

Gender

Spayed/Neutered?

Temperament

Current Health

Please tell us about your existing pets(Required)

Playfulness, sociability, any other significant thing you can think of…this will help find the right new family member for you.

Previous Pets

Have you ever previously owned a dog?(Required)

Yes

How many dogs have you owned in the past 15 years?(Required)

Have you ever previously owned a RESCUE dog?(Required)

Yes

When did you own a Rescue Dog?(Required)

Describe in detail the pets that are no longer with you for any reason, and tell us why(Required)

Please tell us about your previous pets(Required)

Playfulness, sociability, any other significant thing you can think of…this will help find the right new family member for you.

Heartworm Preventative

What heartworm preventative do you use (or used in the past) and where did you purchase this (vet, online, other)? If none, please indicate why not using a heartworm preventive.(Required)

Home Information

In what type of home do you live?(Required)

What type of structure is the home?(Required)

Single Story

Bi-Level

2-Story

Other

Do you live on the ground floor or an upper level?(Required)

Ground Floor

Upper Level

Do you have stairs leading to or inside your home and how many are there?(Required)

Do you rent or own your own?(Required)

Own

Rent

Does your landlord allow pets?(Required)

Yes

Landlord's Name(Required)

First Last

Landlord's Address(Required)

Street Address Address Line 2 City State ZIP Code

Landlord's Phone(Required)

Do you live in a community governed by an HOA?(Required)

Yes

If you do live in a community governed by an HOA, what are the requirements for pet ownership?(Required)

How would you describe the area in which you reside?(Required)

Urban

Suburban

Semi-Rural

Rural

Yard and Fencing

PLEASE NOTE: If you utilize an underground/electronic/electric fence for containment, we will not be able to process your application.

Do you have a yard?(Required)

Yes

Is the yard fenced in?(Required)

Traditional fence, not electric

Yes

Describe the materials & height of fence, and size of yard(Required)

Do you have electric (hidden/underground) fencing or plan to install it?(Required)

Yes

How do you plan to keep your dog from roaming off of your property?(Required)

Do you agree that Terriers should NEVER be left off-leash or outside unless securely fenced in?(Required)

Yes

Plans to care for a dog

Where will the dog be kept during the day?(Required)

Indoors

Outdoors

Both

Indoor Location(Required)

Loose

Crated

Basement

Other

Outdoor Location(Required)

Who will be responsible for feeding, housebreaking/training?(Required)

Myself

My Spouse

My Child

Other

Are you willing to take your dog for obedience lessons if necessary?(Required)

Yes

Will anyone be home during the day?(Required)

Yes

Who will be home & what will their responsibilities be?(Required)

Describe the exercise schedule you will have for your dog(Required)

How many hours a day will the dog be left INSIDE unattended?(Required)

Less than 1 hour

1-2 hours

3-4 hours

5-6 hours

7-9 hours

More than 9 hours

How many hours a day will the dog be left OUTSIDE unattended?(Required)

Less than 1 hour

1-2 hours

3-4 hours

5-6 hours

7-9 hours

More than 9 hours

Never

When you are away on trips, where will the dog be kept?(Required)

Home, someone comes over to feed

Pet sitting service

Board at dog kennel

Other

After the dog has been adequately house-trained, where will it sleep at night?(Required)

What do you intend to feed the dog?(Required)

Preferences

What gender dog do you prefer?(Required)

Male

Female

No Preference

Would you consider a dog of the opposite gender?(Required)

Yes

What age range are you willing to consider for your future rescue dog? Check all that apply.(Required)

Puppy

Youngster (1-3)

Teenager (4-7)

Mature (8-10)

Senior (11+)

Please note our Age Policy: If your age is 21 – 67 years old, you are eligible to adopt any age of dog. If your age is 68 – 77 years old, you are eligible to adopt the following: Teenager (4-7), Mature (8-10), or Senior (11+). Your application will NOT be accepted if you select Puppy or Youngster (1-3). If your age is 78 years old or older, you are eligible to adopt the following: Mature (8-10) or Senior (11+). Your application will NOT be accepted if you select Puppy, Youngster (1-3), or Teenager (4-7).

Would you consider a special needs dog?(Required)

Special Needs dogs could be of any age. They could be a dog with a vision or hearing loss, or have some other medical condition. They could be dogs in their twilight years who need a loving home for the rest of their lives.

Yes

Please list the name(s) of our available dogs that you are interested in. Click the + sign to add additional rows(Required)

Vet Type(Required)

Current Vet

Previous Vet

Not Used Yet

List how long you've used this vet and the names of the animals treated(Required)

List how long ago you used this vet and the names of the animals treated(Required)

Name of Practice(Required)

Name of Doctor(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Vet Reference 2

Vet Type (Reference 2)

Current Vet

Previous Vet

Not Used Yet

List how long you've used this vet and the names of the animals treated

List how long ago you used this vet and the names of the animals treated

Practice Name

Doctor Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Acknowledgement & Consent

How did you hear about us?(Required)

CAPTCHA

This field is for validation purposes and should be left unchanged.

Before hitting submit please note the following:

Your approved application lasts SIX MONTHS and applies to all dogs that are READY for adoption. Approval can take two weeks or more.

Col. Potter is NOT shipping any dogs cargo. If a dog is small enough to fly under the seat in the cabin per the desired airline’s guidelines, the adoptive home may choose this method of transport but they are fully responsible to make all necessary arrangements.

Adoption Application

ATTENTION POTENTIAL ADOPTERS PLEASE TAKE NOTE OF OUR AGE POLICY:

Policy Agreement

General Information

Previous Applications or Adoptions

Household Information

Matchmaking Information

Current Pets

Previous Pets

Heartworm Preventative

Home Information

Yard and Fencing

Plans to care for a dog

Preferences

References

Personal Reference 1

Personal Reference 2

Personal Reference 3

Personal Reference 4

Vet Reference 1

Vet Reference 2

Acknowledgement & Consent

Before hitting submit please note the following:

Your approved application lasts SIX MONTHS and applies to all dogs that are READY for adoption. Approval can take two weeks or more.

Review Cart