Inland Empire Jack Russell Terrier Rescue of So. Cal.

Your answers on this questionnaire will help us to match your needs with the Jack Russell Terriers in our program. Please print, fill out, and mail to address below. Please answer all questions.

Name:
Address:

Email Address

Daytime Phone:

Evening Phone:

Employer:		How Long:		Phone:
Employer:		How Long:		Phone:

Please List 2 References:
Name:		Phone:
Address:
Name:		Phone:
Address:
Is there a JRT you're interested in that is on our web site?		Name:

1. Please circle your preference

Males

Females

No Preference

2. Do you have a color/coat preference? (Circle all that apply)
White/Red	White/Brown	All White
White/Tri	White/Tan	No Color Preference
Smooth Coat	Broken Coat	Rough Coat
3. Do you have an age preference? (Circle all that apply)
Under 1 year	1 - 2 years	2 - 4 years
Over 4 years	No Preference
4. Who is the Jack Russell for?

5. Have you owned a Jack Russell or any dog before? If YES, please give a brief history and reason you do not own him/her anymore:

6. What is it about Jack Russell Terriers that interest you?

6a. Have you done any research on Jack Russell Terriers? (example: read JRT books, called JRT breeders, field trials for JRT's)

7. What other breeds have you considered?

8. Circle the 3 most important characteristics that you would like to see in your Jack Russell
Active	Playful	Independent	Protective	Dominant
Intelligent	Loving	Shy	Aggressive	Submissive
Other: (describe)
9. How do you plan to discipline your dog?

10. To facilitate the bonding process, we highly recommend that every new Jack Russell undergo some introductory obedience training. Would a formal obedience training program interest you as a new dog owner? (Circle one)
YES	NO
11. Which of the following best describes your current residence? (Circle one)
Own House	Rent/Lease House
Own Townhouse/Apartment	Rent/Lease Townhouse or Apartment
Other: (describe)
NOTE: If you rent or lease your residence, proof of permission to have dogs will be required before the adoption is finalized
12. Do you have a fenced yard? (Circle one)
YES	NO
If YES, please describe fence:

Type:
Height:
Number of Gates:
Can children easily open the gates?
13. If your yard is NOT fenced, do you have a secure dog run? (Circle one.)

YES

14. What improvements, if necessary, will you make to secure your yard?


15. If you do not have access to a fenced area at your home, would you like a rescue representative to provide recommendations on the safe confinement of your dog? (Circle one.)
YES	NO - I have already made the following arrangements:

16. Have you checked your yard for dangerous articles, plants or anything the dog could use to climb the fence? (Circle one)
YES	NO
Would you like some assistance from a rescue representative? (Circle one)
YES	NO
Would you object to a rescue representative doing a home visit with the rescue dog that you are interested in? We want to make sure the dog gets along in your environment before we place him/her. Answer required.
YES	NO
If you have a pool, is it fenced? (Circle one)
YES	NO

17. Do strangers (meter readers, etc.) require access to the area your dog will occupy? (Circle one)
YES	NO


18. Are there any distractions outside the yard that may upset the dog? (Neighbor's dog, loose dogs on street, neighborhood children, etc.)
19. Approximately how many hours each day will your dog be alone? (Circle one)
3 hours or less	Between 3 and 6 hours
Between 6 and 12 hours	Between 12 and 18 hours
Longer than 18 hours

20. How will your dog be confined when left home alone?

21. Will the dog be kept primarily indoors or outdoors?

22. Where will the dog sleep at night?

23. What other animals currently live in your home? (Please list ALL) Answers required.
Type of pet	Sex/Age	How Long Owned?	Where kept?

24. How many other people currently live in your home? (Please list ALL) Answers required.
Name	Relation to You		Age





25. Does anyone in your family have allergies to dogs? (Circle one.)
YES		NO
26. Who will have primary responsibility to care for the dog?

26A) If you have chosen a child to care for the dog, who will be the second caretaker?

27. Have you and your family discussed the pros and cons of owning a Jack Russell Terrier? (Circle one)
YES		NO
28. Is everyone in your home enthusiastic about getting a Jack Russell Terrier? (Circle one)
YES		NO
29. Do friends, relatives and children have access to your home, property and car without your supervision?
YES		NO
30. Are you willing to instruct your children and other people that visit your home frequently on the proper handling and care of Jack Russell Terrier? (Circle one)
YES		NO
31. Have you considered the long commitment of time and financial resources required for dog ownership? Costs can run up to $1000.00 for emergencies. (Circle one)
YES		NO
32. Is there a veterinarian that you use now or have used in the past?
YES		NO
If YES, please provide the following:
NAME:
ADDRESS:
PHONE:

Thank you very much for taking the time to complete this questionnaire. Your answers will permit us to more effectively match your needs with dogs in our program. We will contact you by email or phone as soon as we have a JRT that best fits in your home.

If you have any questions or concerns about adopting a rescued Jack Russell Terrier or about this program, please use a blank piece of paper to share them with us. We are always interested and open to your viewpoint.

33. If you do not have a veterinarian, would you like a rescue representative to recommend a veterinarian in your area that is knowledgeable about Jack Russell's? (Circle one)
YES	NO
34. How did you find out about our organization?
Veterinarian (name)
Shelter (name)
Newspaper (name)
Friend (name)
Other (describe)
35. Would you consider volunteering for our organization? (Circle one)
YES	NO

If YES, in which of the following areas: (Circle all that apply)
Foster Care	Transportation of Animals
Telephone Calling	Interviewing adoption candidates
Computer Assistance	Fundraising
Other: (describe)

Adoption Questionnaire