Adoption Form Name * First Last Address * Phone Numbers * Email * Date / Time Are there any children in the home? * yes no What ages are the children? Do you own any other dogs? * yes no Please tell us what breed(s) of dog(s) you have, what sex they are, their ages and whether they are neutered Do you own cats? * yes no Do you have any other pets/livestock? * yes no if so, what do you have? Is someone home all day? * yes no If not, please explain your working hours and arrangements for the dog's care while you are out. How long would the dog be left at any one time? Do you have a secure, enclosed garden? Yes No Please describe your garden, including height of fencing Are you on, or near, a busy road? * Yes No Have you access to good safe walks * Yes No Have you had an Irish Red and White Setter before * Yes No What other breeds have you had in the past and what happened to them Are you, or have you been, banned from keeping animals * Yes No Do you own your own home or are you renting * Select... own rent If you are renting, do you have your landlord's permission to take in a rescue dog? Yes No n/a Do you have a current vet? * Yes No Your current vet's contact information: (name, address, email and phone) Are you prepared to travel to collect a dog * Yes No Are you prepared to deal with the any problems involved with taking on a rescue dog? eg, nervousness, chewing, house-training, lead and recall training * Yes No What sex of dog would you prefer? The more flexbile you can be the sooner a dog may become available. Select... Male Female Either What age of dog are you considering? Please remember that setters can live well into their teens and remain active into 'old age'. Select... up to 12 months 1 - 4 years 4 - 8 years over 8 years any Would you mind telling us what age group you are in? Select... <35 36-50 51-64 >64 Don't wish to say Have you any health issues that could affect your ability to care for the dog properly at all times? Please tell us why you would like to rescue an Irish Red and White Setter and what you feel you can offer the dog. Additional Comments The information you have provided will be securely kept by the IRWS Club of GB, please confirm that you are in agreement with this. * Agree Disagree Thank you for taking the time to complete this form, our Rescue Secretary will be in touch with you when a suitable dog becomes available.