Foster Home Adoption Application Policy AgreementBefore filling out the application, please read the Adoption Policies & Procedures. Adoption Policies & Procedures Acknowledgement I acknowledge that I am at least 21 years of age and that I have read the Adoption Policies & Procedures outlined on the Col. Potter Rescue Network’s website.Do you agree to keep the dog licensed, the CP Identification Tag and your personal infomation identification tag on the dog at all times?(Required) Yes No Do you agree to comply with ALL applicable City/Town, County, State and Federal laws as they relate or pertain to the care, treatment and responsibility of dog ownership?(Required) Yes No Do you agree to contact Cairn Rescue if you can no longer keep this dog?(Required) Yes No Do you need to purchase the foster's crate?(Required) Yes No 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 containement?(Required)We do not adopt our Rescue Cairns to anyone with electric fencing as their primary means of containment. Yes No 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 No General InformationName of Person Filling out the Form(Required) First Last Are you the applicant?(Required) Yes No 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 / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 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 No Second Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Primary Phone(Required)Work PhoneCell PhoneIndicate the best time for a Rescue Contact to call you(Required)Household InformationDoes everyone in the household know that you are applying for a rescue dog and do they all agree?(Required) Yes No Please Explain(Required)Have there been any changes to the people living in your home since your foster application was approved?(Required) Yes No Updates to People Living in HomeList of ADULT FAMILY members currently residing in the household, INCLUDING YOURSELF(Required)Click on the + sign to add additional rowsNameAgeOccupation Add RemoveDo any ADULT NON-FAMILY members currently reside in the household?(Required) Yes No List of ADULT NON-FAMILY members currently residing in the household(Required)Click on the + sign to add additional rowsNameAgeRelationship Add RemoveDo any children under 18 years of age reside in the household?(Required) Yes No List of CHILDREN UNDER THE AGE OF 18 residing in the home(Required)Click on the + sign to add additional rowsNameAgeRelationship Add RemoveDo any children under 18 years of age VISIT FREQUENTLY?(Required) Yes No Please list any children under 18 years of age who VISIT FREQUENTLY(Required)Click on the + sign to add additional rowsNameAgeRelationshipFrequencyTypical Duration Add RemoveDog You Wish to AdoptCP Name(Required)Age(Required)CP Tag#(Required)Microchip Brand & #Issues (Health and/or Behavior)Why do you want to adopt this dog?(Required)Current PetsDo you currently have any pets in your home?(Required) Yes No Have the current pets in your home changed since your foster application was approved?(Required) Yes No Updates to Current PetsList all CURRENT pets(Required)Click on the + sign to add additional rows for each petNameSpeciesAgeGenderSpayed/Neutered?TemperamentCurrent Health Add RemovePlease tell us about your existing pets(Required)Playfulness, sociability, any other significant thing you can think of.Home InformationHas your home information changed since your foster application was approved?(Required) Yes No Updates to Home InformationIn what type of home do you live?(Required) Single Family Townhome Condominium Apartment Cabin Motorhome Boat 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 No Landlord's Name(Required) First Last Landlord's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Landlord's Phone(Required)How would you describe the area in which you reside?(Required) Urban Suburban Semi-Rural Rural Do you have a yard?(Required) Yes No Is the yard fenced in?(Required)Traditional fence, not electric Yes No 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 No 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 No Vet InformationHas your Vet Information changed since your approved Foster Application? Yes No Vet Reference 1Vet 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Vet Reference 2Vet Type (Reference 2) Current Vet Previous Vet Not Used Yet List how long you've used this vet and the names of the animals treatedList how long ago you used this vet and the names of the animals treatedPractice NameDoctor Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneAcknowledgement & ConsentConsent(Required)By submitting this application, you give us your permission to call all of your listed references, including your Veterinarian(s), to determine responsible pet ownership. If you have included a work telephone number for any of your references, you are stating that they may receive telephone calls at their place of employment.Your signature(s) will be required on a formal Adoption Contract prior to adopting any rescue dog. You must also provide proof of being of legal age in your state to sign contracts. Photographic identification with your current address may be required prior to adoption.I represent that the information that I have provided on this form is the truth to the best of my knowledge and belief. I/we hereby give my/our permission to CPCRN to use any of the above information to confirm that this rescue application is deemed to be correct. I hereby certify that I have not been convicted or otherwise been found guilty by any governmental authority of animal cruelty, neglect or abandonment, or of failing to provide adequate shelter to an animal.I understand that CPCRN may, at its sole discretion, determine that a Cairn rescue will not be approved for adoption by me or my family. I acknowledge that I have read, understand, and agree to these policies and proceduresCAPTCHANameThis field is for validation purposes and should be left unchanged.
