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The Clumber Spaniel Rescue Charitable Trust - DOC

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					CLUMBER SPANIEL CLUB OF AMERICA, INC.
RESCUE & PLACEMENT COMMITTEE
41 COMPTON COURT BASKING RIDGE, NJ 07920 908.580.1055

PLACEMENT QUESTIONNAIRE - “FOR NEW ADOPTIVE HOMES”

Name: Address:

Date: Phone: (Day) (Eve.)
Cell:

E-Mail: FAX: Occupation:

1.

Why are you interested in adopting a Clumber Spaniel?

2.

What experience and/or exposure have you had to Clumbers before? Please describe if you’ve made the necessary home visit with a CSCA member or breeder.

3.

What type of Clumber are you looking for? Male ____ Female ___ Under 5 years ___ Over 5 years ____ No preference ____

4.

Will you license this Clumber in accordance with municipal and state laws?

5.

Have you had pets before? If yes, what kind?

6.

What happened to the pets you previously owned? Have you ever given up a pet voluntarily? If so, why?

7.

Have you ever been in a court situation regarding your ownership of any dog? If so, please describe.

8.

Do you currently have other pets? What kind and how many? What are their ages and sex? Are they spayed/neutered? How are they with other dogs and new visitors?

9.

Are there children in your household? If yes, how many and what are their ages?

10.

Do your children and pets have a lot of exposure to other animals where you live? Do other children and pets visit regularly?

11.

Do you rent or own your home? If you rent, do you have your landlord’s permission to keep a dog? Can you provide us with a letter indicating this permission?

12.

Do you live in an apartment, single-family house, condominium, on a farm, etc.?

13.

Do you have a fenced yard? If so, please describe in detail. Do you have a dog run and what is its size?

14.

Do you own a crate?

15.

Are you willing to crate your dog for short periods? Do you keep your dog crated during the workday if no one is at home?

16.

Where will you keep the dog during the daytime and at night?

17.

How much time will the dog spend alone?

18.

What do you most enjoy doing with your pet(s)?

19.

Is there an activity you’d most like to pursue with a Clumber? (i.e., hunting, tracking, agility, obedience or therapy work?

20.

Do you have adequate time in the evenings and on weekends to spend with your pet(s)?

21.

Do you travel frequently for work and/or for pleasure?

22.

What arrangements would you make for your pet(s) in your absence?

23.

Are you willing to accept the costs of any veterinary care your Clumber may require (including spay/neutering, if necessary)?

24.

Can you provide us with a veterinary reference?

25.

Would you be willing to adopt a Clumber with some type of disability? Yes_____ No_____ Depends on condition______

26.

Would you be willing to adopt a Clumber with any type of behavioral issue that needed corrective training or modification? Would you be willing to attend obedience classes with this dog, if recommended?

27.

Additional comments:

For more information, please contact one of our Rescue & Placement Committee members:

Sue Carr, R&P Chair, CSCA 41 Compton Court Basking Ridge, NJ 07920 (908) 580-1055 Email: scarr41@optonline.net

Marilee Hejna Elizabeth, IL 815-598-3391 Crabapple@bhawk.net

Donna Starr Watsonville, CA 831-722-9807 DonnaS@westmarine.com

Denise Shelar Beacon Falls, CT 203-888-5325 w00dclmbe@aol.com

Barbara Stebbins Port St. Lucie, FL 772-336-8574 Terryville@bellsouth.net

*Please note that any or all of the following expenses are the responsibility of the new adoptive home: 1. 2. 3. Shipping of the dog Spaying or neutering, if applicable Humane Society or shelter reimbursement, if applicable

We also require a $150.00 fee prepaid upon placement to the Rescue & Placement Committee to help recover a percentage of our operating expenses and to cover the cost of microchipping each adoptive Clumber.