How did you learn about RAGOM?

1. Please list all members of your household with their ages, including your pets.

   Humans:		Ages:
   Dogs:		Ages:
   Cats:		Ages:
   Other Pets:		Ages:

2. If you do not have small children living in your home, will your rescue golden come into contact with any children under the age of 10? If yes, how often and what ages?
   
3. Do you have an in-home day care?   Yes   No
4. If you do not have a dog now, have you ever owned a dog for whom you were the primary caretaker? 
   Please specify breed and gender:
   
5. Have you ever surrendered a dog?   Yes   No
   If so, please explain:
6. Have you ever lost a dog to an accident?   Yes   No
   If so, please explain:
7. Please tell us why you want a Golden Retriever:
   
8. Why do you think you would be a good adopter for a rescue golden?
   
9. How will you exercise your rescue golden?
   
10. Where will your rescue golden be kept when the humans are away from the home during the day?
    
11. How many hours will your rescue golden be alone (without humans) on a regular basis?
    
12. Where will your rescue golden sleep at night?
    
13. Who is your veterinarian? Please list phone number.
    
14. Is your home a:
        House
        Condo/Townhouse
        Apartment

    If you rent, has your landlord provided written permission for you to have a large dog?
    

15. Do you have a fenced yard?   Yes   No

    Type and length, width and height of fence:
    

16. Do all family members want a dog?
    
17.   If we called you tomorrow with a perfect dog for your family, would you be ready to adopt?

        Yes
         No

Gender:
    Male
    Female
    Either

Age:
    8 weeks - 6 months
    6 months - 1 year
    1 year - 2 years
    2 years - 4 years
    4 years - 6 years
    6 years - 8 years
    Senior - 8 years plus

Purpose:
    Family Pet
    Obedience
    Walking/Jogging
    Hunting
    Therapy Work
    Agility

I/we would likely be available for a Home Visit (please choose times when you entire family will be available):

    Weekdays
    Weekday Evenings
    Weekend Morning
    Weekend Afternoons
    Weekend Evenings

Comments:

Agreement

Thank you so much for your interest in a rescued Golden Retriever from RAGOM. By completing this application, you will be taking the first step toward welcoming a wonderful new companion into your family! RAGOM is a non-profit, all-volunteer organization, with all of our foster care, transport, application reviews, home visits, and placement activities performed by volunteers.  Last year, RAGOM placed over 200 goldens in new homes.

Because of the time and effort required to place a rescued golden into a new family, we require a $25.00 application fee at the time of application. After submitting this form you will be given the option to send us a check or pay online by credit card.

As soon as your application donation is received, we will begin processing your application.  If your application is accepted and you are approved as an adoptive home for a RAGOM dog, the application donation will be non-refundable.  Please remember that finding the perfect rescue golden for your family may take anywhere from 3 weeks to 3 months after your application has been accepted.  If your application is denied by RAGOM at any point during the application process, your application donation will be refunded immediately.  Again, thank you for opening your home and your heart to a rescued Golden Retriever!

If the applicant is approved by RAGOM as being eligible for adopting a RAGOM Golden, the following will be agreed to by the applicant:

*To be personally responsible for the humane care, proper food, water, shelter, regular exercise, veterinary care and control of their RAGOM Golden at all times.

*The RAGOM Golden will be spayed or neutered prior to entering the applicant's home or at the first medically possible time.

*RAGOM can make no warranty about the health condition or temperament of this Golden and that RAGOM can only provide information based on observations at the shelter and/or from the previous owner.

*The applicant must return the Golden to RAGOM if the applicant does not want or can no longer take care of the animal.

*The RAGOM Golden shall not be tied out (chained, roped, etc.) at the applicant's home for extended periods of time.

*If determined by RAGOM that any RAGOM dog is not receiving proper care, RAGOM may take the dog from the applicant.

*To aid in covering the costs associated with re-homing the dogs, for dogs who have not reached their 4th birthday, a $275.00 fee is required.  For dogs from 4 years through 8 years, a fee of $225.00 is required.  For senior dogs who have reached their 9th birthday, a fee of  $125.00 is required.  

*By checking this box the applicant certifies that all information provided to RAGOM is correct.

Today's date is:  
Applicant's Name:   
Co-applicant's Name: