Employer
Street
City: State Zip Work
phone
Do you work
outside of the home?
Employer: Phone
Number:
Nature of job
(optional):
Employer (spouse)
Work Phone:
Nature of job
(optional):
Have you ever
owned a Dachshund?
How long have
you owned a dachshund(s)
Are you familiar
with all of the breed characteristics?
Do you know
all of the colors and patterns of the dachshund for proper identification?
Dachshunds come
in two AKC recognized sizes. What are they? &
There is a slang
word for an oversized mini that shows up only in the pet breeding of dachshunds,
list what this term is if you know it.
Do you currently
own a dog(s)? Yes No
Do you currently
own a cat(s)? Yes No
*If you own
a dog/cat, are they altered?
Dogs: Yes No
Cats: Yes No
Are your current
pets (dogs, cats, ferrets) that require vaccines UTD (up to date)? Yes No*
*If "No" please
explain why.
Are your current
pets that require rabies current? (one year or 3 year required vaccine) Yes No*
*If "No" please
explain why
Will you be able
to foster a CCDR rescue? Yes* No*
Type of residence?
Do you
*Is the landlord
on the premises? Yes* No*
*Written documentation
from landlord or proof of pet deposit required prior to fostering.
Landlord's Name
Street City:
State Zip:
Work phone
Do you have
a yard? Yes No
Approximate
size
Completely fenced? Yes* No
*If yes, type/height?
If no, are you
willing to fence, install a pen or run, or leash walk at all times? Yes* No*
*Please specify
In cases of
inclement weather, is there shelter outside for the Dachshund? Yes No
Are there stairs
in your residence? Yes No
Are you planning
to move in the next 6 months? Yes No
Would your pets
accept a new dog? Yes No Not
Sure
Do you often
have other people visiting your home? Yes No
Grandchildren? Yes No
Other children? Yes No
Where will the
dog be kept during the day?
At night?
When left alone?
How many hours
a day will the dog be at home alone?
Where will the
dog sleep?
Where and how
will the dog exercised?
Have you ever
housebroken a dog before? Yes* No
*What method
did you use?
Would you accept
a dog that is:
Older? Yes No
Recovering from
medical treatment? Yes No
Proven unreliable
with children? Yes No
Previously abused? Yes No
Physical handicap? Yes No
Pregnant and
will be whelping? Yes No
Have you ever
whelped a litter? Yes No
Do you currently
own any other pets? Yes* No
*If yes, continue.
If no, please proceed to (3)
Please list species,
breed, sex, whether the pet is neutered or spayed, note if the pet is kept
inside or outside and how long you have owned this pet. (the neuter and
spay question refers only to cats and dogs)
Please type your
answers in the boxes and check the appropriate box whether your dog is
altered or not.
Species Breed
Sex
Is your pet altered? (spayed or neutered)
Yes this pet is altered
No, my pet is not altered yet Age Kept
In/Out Owned
How Long
Species Breed Sex Is
your pet altered? (spayed or neutered)
Yes this pet is altered
No, my pet is not altered yet Age Kept
In/Out Owned
How Long
Species Breed Sex Is
your pet altered? (spayed or neutered)
Yes this pet is altered
No, my pet is not altered yet Age Kept
In/Out Owned
How Long
Species Breed Sex Is
your pet altered? (spayed or neutered)
Yes this pet is altered
No, my pet is not altered yet Age Kept
In/Out Owned
How Long
If you have other dogs or
cats please add the same information that is above in this text box. Please
tell
us about all of your dogs and cats.
(Altering (spay
or neuter) is in reference to a cat or a dog only)
Are your pets
current on Heartworm preventative? Yes* No Not
Sure
*What kind?
How often are
they tested for Heartworms?
How would your
characterize your pets? (dominant, submissive, playful, etc.)
If you have previously owned
pets, what happened to those no longer living with you?
Have you bred any of your
current or past dogs/cats to have puppies/kittens? Yes No
Dachshunds can be very prey
oriented. Do you have small pets (rodents, birds, etc.) Yes No
We wouldn't want anything
to happen to a small pet and since a foster dog coming into your home may
or may not have a high prey drive, are you willing to put your small pets
in a very safe place until you get to know the behavior of the foster dog? Yes No
CCDR cannot be responsible
should a foster dog injure a small pet. Please understand you are taking
full responsibility to protect your small pets and undersand CCDR is not
liable if something happens to them. Dachshunds have a high prey drive
and you must be very diligent in protecting those pets who may be at risk.
Do you agree to this requirement? Yes No
Please list the name,
age, and relationship of those residing with you.
Name Relationship Age
Name RelationshipAge
Name Relationship Age
Name Relationship Age
Name Relationship Age
Dog Experience
Please describe any experience
you have in training (do you do AKC events, obedience, agility, other dachshund
sports.)
Do you have experience with
rehbilitating dogs that have emotional issues? (abuse, puppy mill dog,
lack of socialization)Yes No
Do you have any experience
with physical rehabilitation (a dog who has had back surgery, broken bones,
surgery, etc.) Yes No
Some rescue dachshunds have
problems with separation anxiety, fearfulness or dominant behavior. Would
you be willing to help retrain a dog following a specific behavioral remediation
program that included support from a trained professional?
Yes No
If necessary, would you
be willing to take a foster dog to obedience training (at CCDR's expense)
or to obedience train him yourself? Yes No
Other Organization Affiliations
Have you been a member or
helped any other type of rescue organization (other than dachshund)? Yes No
What breed and what is the
name of the organization.
Are you still a member of
another rescue group? Yes No
Have you been a member of
any dachshund rescue organization? Yes No
(CCDR does not allow dual
memberships (where you are a current member of another dachshund rescue
group) between CCDR and other dachshund rescue organizations but you may
belong to other rescue groups that are not specific to dachshunds)
If you are or have been
with another dachshund rescue organization(s), what is the name of the
organization(s) Please list most current and all of those you've been a
member of or volunteered with, how long you were a member and why you left.
Please list the president
or a board member's name and email where we can contact them for
a reference.
If you prefer we not contact
the president or board member, please explain why and provide a reference
(another member) as a reference. We understand there can be sensitive reasons
why you left or wish us not to contact an officer. Please explain in full
though. Your answer will be kept private.
Please list any other animal
welfare affiliations, months/years of membership, and general responsibilities*.
*General responsibility
may represent financial endorsement and does not have to be a titled position
within the organization.
Name of Organization(s)
Months/Years
General Responsibility
If you are involved with
other pure breed or all breed rescues organizations will you agree to process
all rescued dachshunds solely through CCDR, based on our policies and procedures? Yes No*
*If no, please explain (you
must explain in full why you would not process a dog through CCDR).
Shelters
Have you ever rescued a
dog from a shelter? Yes No
Are you willing to pull
a dog from a shelter? Yes No
Do you feel it is important
to maintain a working relationship with a shelter? Yes* No*
*Please explain your reason
whether "yes" or "no".
Do you currently have a
contact at your shelter? Yes No
Are you aware that many
shelters cannot accurately estimate the day of euthanasia? Yes No
Owner Surrenders
Have you ever rescued a
dog surrendered by the owner? Yes No
Owner surrenders can be
emotional. Are you willing to empathize with an owner prior to the dog's
surrender and keep it professional? Yes* No*
Do you understand the importance
of an owner signed surrender form? (CCDR has these forms available within
the organization) Yes No
Placement Screening Process
Have you ever placed a rescued
dog? Yes* No
*If yes, did you place the
rescue as: A
member of a rescue organization. Which one?
Independently Both
Was the dog altered before
placing them in their adoptive home? Yes No
Have you ever screened a
potential applicant? Yes** No
**If yes, continue. If no,
please proceed to (10.)
Which of the following did
you use in the screening process? Application Home
CheckReference
Check Veterinary
Reference
Was the dog spayed/neutered
prior to placement?Yes No
*Did you contractually require
proof of spay/neuter at an agreed upon date? Yes No
Was the dog up to date on
shots prior to placement? Yes No
Did you use an adoption
contract with your placements? Yes No
Transports
Would you be willing to
assist in transporting Dachshunds? Yes* No
*What length of time are
you willing to drive?
Public Relations
Are you willing to correspond
with the general public in a professional and educational manner?Yes* No
Not
Sure
*Even when their beliefs
are contrary to the mission of rescue? Yes** No
Are you able to respond
to an interested party within a 2 day time span? Yes No
Skills
Do you have any special
skills (managerial, coordinator, accounting, etc) that might be helpful
in assisting CCDR in its mission? Yes* No
*If so, please elaborate
*Veterinarian:
YOU
MUST fill this information out even if you do not currently have a dog.
If you've never had a dog and never established a veterinarian , put n/a.
Veterinarian's
name, Clinic Name, Address, Phone number and email address
*References:
YOU
MUST FIll out all 3 references.
*Reference
1
*Reference
2 (Not related to you)
*Reference
3 (Not related to you)
*Hold
Harmless-Required Reading
By
inserting a check mark next to the following statements, you agree to all
conditions set forth by Coast to Coast Dachshund Rescue.
I
understand that Coast to Coast Dachshund Rescue is a private, non-profit,
all-volunteer organization devoted to rescuing and placing dachshund and
dachshund mixes in need.
Because
of my intention to aid CCDR in its charitable pursuits, I agree to hold
CCDR, and/or representatives thereof, free and harmless from any loss,
damages, injury or death to any person, animal or property caused by the
CCDR dachshund(s) placed in my custody. I understand dogs coming into rescue
may demonstrate behavior that may cause conflict temporarily in a home
with existing animals, therefore, I will exercise great care and take full
responsibility to ensure that any animal (CCDR dog, my own private animals,
children, adults) are taken into consideration and will never put anyone
or anything at risk. I will secure a rescue dog safely in all new or existing
circumstances until I am sure how the rescue dog will respond in the new
environment. I will not assume a dog will bite under stressful circumstances
and will take precautions until I am confident of the dog's comfort level
in it's temporary home.
I
am aware that the CCDR dog(s) may have undetectable illnesses. Further
I realize that CCDR is responsible only for the medical care of the CCDR
dog(s) and that I, alone, am responsible for any acts for the CCDR dog(s),
once placed in my custody and under my care.
I
understand that the veterinarian, CCDR, or representatives thereof, are
taking no responsibility as to the character or disposition of the CCDR
dog(s).
I
will contact my CCDR mentor immediately should the foster dog become lost,
stolen, seriously ill or die and/or bite in an aggressive manner. "Contact"
shall mean verbal communication between your CCDR mentor, and/or a board
member thereof, either by telephone or in person.
The
foster dog will wear a CCDR ID or a regular ID tag at all times.
I
understand that there is a 4 month probationary period for all associate
members. If at the end of that probationary period the associate member
is in good standing and has demonstrated a full understanding of CCDR policies
and procedures, they will be offered a full membership opportunity. At
this time they associate member will be expected to pay the full membership
dues of $30.00 a year.
Upon
receipt and review and prior to official membership, I agree to follow
the CCDR policies and procedures and uphold the Members' Code of Ethics.
Are you working with a CCDR
member? Yes* No
*If so, please provide name
Please list who you know
in CCDR or who you have been working with. Select the one you'd like to
have as your mentor.
Name: Member's
email:
Name: Member's
email:
Name: Member's
email:
Name: Member's
email:
I
understand that I must complete an associate membership of 4 months under
the supervision of a mentor who is a full CCDR member before being invited
to join CCDR as a full member with full member privileges. At the time
of acceptance (after the 4 month training period) I understand I must pay
my yearly dues of $30.00 before receiving CCDR member material or becoming
a full member. I understand this a valuable training period and will be
able to perform all membership functions except the actual adoption of
a CCDR dog. I certify that I am at least 21 years of age and that I will
be solely responsible for the care and well being of any dog that I foster
for CCDR. Any misrepresentation of the true facts in this Member application
will invalidate my CCDR associate membership and privileges and will give
CCDR the right to immediately reclaim any and all CCDR foster dogs in my
care. |