Dog Adoption Application 2017

We are unable to do adoptions for residents of Massachusetts at this time.
Please complete all fields applicable to your application. Blanks fields will cause a delay in processing your application.
EXAMPLE: If you rent, but do not provide your landlord's contact information, your application will be delayed.

Prior to approval of your application, we require a vet check on your existing pets, a landlord check, if applicable, and a home visit. Some home visits are conducted in person, while others are conducted virtually.

I acknowledge and accept these terms. *

Yes, I understand there will be a home visit.

Applicant Information

ATTENTION AOL USERS - Please add @thepixelfund.org to your "Safe List" to ensure you receive emails from us about your application. Thanks!

Are you currently applying or inquiring about an adoption with other rescue organizations, humane society or breeders? *

Yes No

Are you able to do Skype or Facetime? (If you live in a remote area where we don't have someone who can do a home visit, this is an alternative.) *

Yes No

Needs & Expectations

Ages of all family members, including self, that live with your or visit often *

Does anyone in your household have allergies to animals? *

Yes No

May we visit your home prior to application approval? *

Yes No

If Yes, when is the best time? *

Tell us about your current and previous pets...

Name (to validate vet records) *

Species-Gender *

Spayed/Neutered? *

Yes No

What happened to the pet? *

Name (to validate vet records) *

Species-Gender *

Spayed/Neutered *

Yes No

What happened to the pet? *

Name (to validate vet record) *

Species-Gender *

Spayed/Neutered *

Yes No

What happened to the pet? *

Veterinary Information

Current Veterinarian *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

I have notified my vet of my intent to adopt a dog and asked them to release information to The Pixel Fund. *

Yes No

Previous Veterinarian *

Phone Number *

Do you rent or own? *

Landlord's Name *

Landlord's Phone Number *

Do you have permission from your landlord to have a pet? *

Yes No

What size pet are you allowed to have in your rented home (check all that apply)? *

Small Medium Large

Dog Adoption Information

Where will the dog stay when you are away from the house? *

How long will the dog be left alone (without humans)? *

Where will the dog sleep at night? *

Will you put your pet on year-round heartworm preventative? *

Yes No

Will the pet you are adopting be allowed in the house? *

Yes No

Bringing a New Dog into Your Home

How do you plan to help your new dog adjust to your home? *

How do you plan on socializing your new dog? *

What behaviors do you consider unacceptable? *

What would happen if your dog developed a physical or behavioral ailment or problem that you felt you could not handle? *

How will you handle excessive barking, fearfulness, jumping, aggression towards other dogs, chewing, potty accidents, separation anxiety, etc. should any of these issues arise? Please understand many of these actions are common during the first few weeks as the new pet adjusts to your home. *

Getting to Know You

Please tell us a little of your lifestyle, your family including any special activities in which your dog would be included. If you have any requirements or requests for a dog, please let us know so that we can more carefully match a dog to your lifestyle. *

Have you ever sold, given away, or surrendered a pet to a shelter? *

Yes No

If Yes, please describe the circumstances. *

When you go on vacation who will care for your dog and where will it be care for? *

Release of Liability

If and when you move, what will you do with your pet? *

Do you understand the state and local ordinances concerning vaccinations, licensing and leashing? *

Yes No

Have you, or any member of your family/household ever been cited for leash law violations or cruelty to animals in the past? *

Yes No

If Yes, please specify circumstances and dates. *

Is there anything else you'd like us to know? *

You will accept the animal and specifically release and hold harmless The Pixel Fund, Pixel’s Posse, Inc., and all of its agents, employees, directors, officers and volunteers from any and all claims and liability in connection with the animal for any reason, and you assume all risks and responsibilities for the care, transport, training and behavior of the animal, including any injury or damage it may cause to people, property or other animals, as well as any rules, regulations or requirements for the importation of pets into the state in which you reside (if you do not reside in Maine or Florida), and licensure and other local ordinances.

No warranties of any kind, including but not limited to health, temperament, viability, age or breed are made by The Pixel Fund. After 5 days, the adoption/re-homing fee is non-refundable and non-transferable.

I/we attest that the information provided on this application is true and accurate to the best of my/our knowledge. I/we understand that completion and submission of this application does not guarantee adoption of a pet. I/we understand that any application and/or rehoming fee is non-refundable and is payable to cover the costs incurred by The Pixel Fund for shelter fees, veterinary care and medical attention, transport, and other expenses, including the care and feeding of its animals prior to adoption. No warranties are made regarding the health, history or temperament of this animal, express or implied. By signing below, you specifically agree that your veterinarian, landlord and employer may release information to The Pixel Fund only with respect to information necessary to process this application.

By typing your name below, you electronically sign/agree to the terms and conditions outlined above.

Please be aware: These applications are processed by volunteers who have full time jobs and families. It may take from 2-7 days to hear back from someone about your application. If we are unable to reach you by phone, we may send an email - so please check your junk mail or spam folders in case those responses end up there. Thank you for your patience and consideration of our volunteers.

﻿Dog Adopt﻿ion App﻿lica﻿tion﻿

Bringing a New Dog into Your Home

Release of Liability

Dog Adoption Application