Adoption Application | MidAmerica Boston Terrier Rescue

List all persons and AGE residing in your home. One per line. Include yourself, spouse, children, roommates. (Name, age, relationship)

If something were to happen to you and you could no longer care for your pet, what is your contingency plan?

If you DO NOT have a fenced in area, please explain why. Exceptions with a leash law enforced are: live in an apartment, covenants or lease agreement do not permit one.

Reference 1 (Name, Phone Number, Email)

Reference 2 (Name, Phone Number, Email)

Please list all animals currently living in the household. Include: Name, Species, Breed, Age. No pets state "none"

If you answered "Yes" to the previous question, please explain why:

Please explain if you have ever had a pet go missing and/or had one die from an accident:

Please explain if you have ever had to put a pet to sleep or had a pet pass away in your care:

Please explain if you have ever surrendered or returned a pet to a shelter, rescue or individual:

Please use the space below to tell us more about your family and why you are interested in this specific dog. What is it about your family that we should consider you over the other approved applicants?

Additional Comments