Adoption App

Adopt a Back Roads Rescue

Please complete this application for consideration for foster/adoption of any of our rescue animals. Adoption fees range from $150-250, depending on the needs of the animal (standard dog adoption fee is $200) and includes complete veterinary care. IF YOU CANNOT AFFORD THIS ADOPTION FEE, PLEASE DO NOT SUBMIT THIS APPLICATION. We pay all costs for all animals and if we didn't recoup SOME of these expenses then we could not continue our rescue work.

* Indicates required field

What pet(s) are you interested in? *

Name *

First

Last

Occupation *

Email *

Home Phone *

Cell Phone *

Do you text *

Yes No

Address *

Line 1

Line 2

City

State

Zip Code

Country

How long have you lived at this address *

Family & Housing

How many adults are there in your family and what is their relationship to you? *

How many children are there in your family and what are their ages? *

What type of home do you live in? *

If you rent, please describe rules governing pets *

If you rent, what is your landlords name and contact information? *

Does anyone in your family have a known allergy to animals? *

Yes No Other

Is everyone in agreement with the decision to adopt a pet? *

Yes No Other

Do you have time to provide adequate love, attention and exercise for the animal you wish to adopt? *

Yes No Other

Other Pets

What other pets do you have (specify type and number)? *

Are your current pets up to date on vaccinations, heartworm prevention, etc? *

Yes No Other

If you answered no to the previous question, please explain in detail: *

Are your current pets spayed or neutered? If not, please explain in depth your reasoning *

Have you ever surrendered a pet (to another person, animal shelter, etc)? If so, please explain in depth the circumstances surrounding the surrender *

Have you ever euthanized a pet for any reason besides old age? If yes, please explain: *

Have you ever lost a pet to an accident? If so, please explain *

How do you discipline your pets? *

Veterinarian Information

By providing us with this information you are allowing a representative from our organization to contact your vet. You will need to call your vet to authorize the release of information.

Do you have a regular veterinarian? *

Yes No Other

Veterinarian's Name and/or Clinic Name *

Veterinarian's Phone Number *

About the Rescue you wish to adopt:

Desired Age *

Desired Breed *

What breed would you not consider adopting? *

Desired Gender *

Neutered Male Spayed Female

Where will your adopted pet spend the day (describe)? *

Where will your adopted pet spend the night (describe)? *

How many hours per day will your adopted pet spend unsupervised (on average)? *

Who will have primary responsibility for your adopted pet's daily care? *

Who will have financial responsibility for your adopted pet? *

Do you agree to provide regular health care by a licensed veterinarian? *

Yes No Other

When/if your adopted pet goes outside, how will you contain them to protect from injury and danger? *

Do you agree to contact Back Roads Animal Rescue if you can no longer keep your adopted pet for any reason? *

Yes No Other

Are you willing to allow a representative from our organization visit your home by appointment? *

Yes No Other

Personal References

We ask for three personal references, at least one of them cannot be a relative

Name of First Reference *

First

Last

Phone # of First Reference *

Email of First Reference *

Relationship to you: *

Name of Second Reference *

First

Last

Phone # of Second Reference *

Email of Second Reference *

Relationship to you: *

Name of Third Reference *

First

Last

Phone # of Third Reference *

Email of Third Reference *

Relationship to you *

If approved, we will contact you as soon as possible
We will ask you to sign an adoption agreement at the time of adoption

Submit

Adopt a Back Roads Rescue

​Family & Housing

Other Pets

Veterinarian Information

About the Rescue you wish to adopt:

Personal References

Family & Housing