It Takes A Village 
​Rescue and Adoption
a non profit organization
 910-514-4176
 706-980-0702
Download
Name:
Date of Birth:
Current Address:
Phone:
E-mail:
Type of Home (house/apt./mobile):
If you had to relocate, what would your plan be for the dog?
Dog Name:
Own/Rent? (If Rent, are you allowed pets)?
# of Individuals in household:
Ages?
Describe your yard size (fenced? type? height?):
Will you use a Crate?
How often?
How will you exercise dog?
Employer:
Phone:
Occupation:
Name of a relative not residing with you (Emergency Contact):
Address (City/State/Zip Code)
Phone:
Relationship:
Describe your yard (size, fence height, and type):
# Hours of Day dog will be crated:
Name of Vet:
Address:
Current pets (names and ages):
Personalities:
Vaccinated?
On Heartworm Prevention?
Rabies?
Describe your relationship to them?
How do you discipline your pet?
Have you ever rehomed/lost/or euthanized a pet? If yes, please explain:
References (2 - No family members: Names/Relationship/Phone Numbers)
Please tell us any other Relevant Info you would like us to know:
Is everyone in home agreeing to the adoption?
Do you agree to provide medical care to the dog?
Do you agree to contact It Takes a Village if for any reason you can no longer keep the dog?
Do you agree to never gift/rehome/surrender the dog?
Do you agree to provide adequate exercise and attention?
Do you agree to never use physical force to discipline the dog?
Electronic Signature (First and Last Name):
Date:
Submit
I Authorize the verification of the information provided on this form as to my references and information. I have printed a copy of this application and read the agreement and terms of adopting.