First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone*

Alt Email

By checking Yes, you understand and agree that we DO NOT adopt out of state (including Canada) OR over 1 1/2 hours away from Buffalo, NY. NO exceptions. Please do not apply. (Any travel IN our adoption area is at the discretion of the foster home.)*

Best phone number to contact you*

Date of Birth (Note: You Must Be 25 Years or Older To Adopt A Dog)*

Your Occupation*

Marital Status*

Spouse/Significant Other's Name*

Spouse/Significant Other's Date of Birth*

Spouse's Occupation*

The Best Time to Contact Me Is (Please expect to be emailed as that is the quickest and easiest form of communication for our volunteers. Please check your spam/junk folders):

When are you able to adopt? We cannot "hold" a dog for you. If you are considering adopting a dog but are unable to take full ownership within 24 hours of the home visit, please WAIT until you are able to apply.*

I currently live in a *
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Please provide your Landlord's contact information (Name/Phone #)

Is your yard fenced? If you have 2 or more dogs currently and want to adopt another, we require a fully fenced yard. *
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

If you answered yes, please describe your fence (Wood, Chain link, Invisible) and height

If you do not have a fully fenced yard, how do you plan on pottying your dog?*

How long have you lived at your current residence?*

How many people live in your home? Please list their names, ages, and relationship to you*

Do you have children that visit? If yes, what are their ages and how often do they visit?

Does anyone in your household have allergies to animals? *

If yes, how do you manage/treat them?

Does anyone in your household smoke? *

Are you interested in a particular dog?
Choose an animal: Benny Cheddar Harvey Kenzie Lexie Libby Lottie Louie Max Mei Ollie Pepper Jack Sally Sawyer Shamus Tracker

Please list any other adoptable dogs you may be interested in

Who will be primarily responsible for the care of this pet?*

Please describe all pets currently with you (age, sex, altered status, BREEDS, WEIGHTS. Please note - If you have a current pet or pets, they must be up to date on vaccinations and spayed/neutered. This includes cats. Dogs must have annual vet exams.) *

If not altered and/or up to date on vaccines- why?

Have you ever put a pet to sleep for non-medical reasons?*
Choose one: Yes No

If you answered yes, please explain

Have you ever given up a pet to either a shelter or rehomed him/her? *
Choose one: Yes No

If you answered yes, please explain

Please describe pets that are no longer with you (type, sex), and what happened to them. *

What type of Food do you feed your current pets? (Brand, wet/dry)

Do you have a regular veterinarian? (Please call your Vet to okay the release of information)*
Choose one: Yes No

Account Holder's Name

Veterinarian’s Name: (You MUST call your vet's office and give permission to release information to PMR) Please list ALL veterinarians that your pets see

Veterinarian’s Phone Number:

  Please contact your vet's office and give permission to release information to Pixie Mamas Rescue!   

Please list two personal references (non-relative), Name, Address, Phone Number: *

Please list 2 relatives as references (Name, Phone Number, Relationship) *

Please list any preferences you have in adopting a dog: *

Would you consider a special needs dog (age, temperament, medical needs)

How much time will the animal spend alone during the day*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal be kept when you are not home*

Please list any other information/comments you feel may be helpful in placing a dog in your home

By checking YES, you understand that an adoption fee is required for each animal and that it is Non-Refundable. *
Choose one: Yes No

I certify that the information contained in this application is true and correct and I understand that prior to the placement of a rescue dog/cat in my home, the information will be verified. I also agree to a personal interview to determine the suitability of my home and family to care for a dog/cat. I agree to allow a Pixie Mamas Rescue representative to visit my home. I am also aware that there is an non-refundable adoption fee for the dog/cat. *
Choose one: Yes No

By checking this box, you give Pixie Mamas Rescue permission to schedule a home visit with the animal of your interest, and upon doing so, you acknowledge that as the Premises of the Owner or Occupier, our animals, guests, items and activities thereon, could pose dangers to people and other animals. Such dangers include, by way of example and not limitation, animals that can bite, trip, knock down, and fight, persons who cannot control their dogs, and activities involving dogs/cats that can result in injury from bites or other causes. Accordingly on behalf of the PMR representative, the Owner or Occupier or his/her spouse and minor children, and anyone else who is on the Premises of the Owner or Occupier, (a) waives any and all legal duties on the part of PMR and assumes the risk of injuries, losses, damages, costs and expenses by any means above described, and other injuries, losses, damages, costs and expenses of every possible cause and description unless inflicted intentionally or recklessly by the agents and employees of Owner or Occupier.

By checking YES, you understand that Pixie Mamas Rescue has the right to either deny or approve your application without explanation. A denial is not a rejection of you as a person; it is a refusal to place a pet in a situation that we do not feel is a good match or does not meet our policies. *
Choose one: Yes No

By checking yes, you understand it is not possible to contact every applicant. All applications are sent to the foster home and if they feel it is a match, they will contact you via email. Please check your spam/junk mail.