On-Line Adoption Application

Thank you for your interest in Lily Rock Belgian's Rescue Program. The ownership of a Belgian Shepherd, like any pet, is a serious responsibility that requires a long-term commitment. It is the goal of the Lily Rock Belgian Rescue program to be sure that this responsibility, as well as the financial, physical and psychological needs of each Belgian Shepherd be met in its new home.

This application has been designed to help prospective Belgian Shepherd adopters address the issues that will directly affect their home, and its suitability for a Belgian Shepherd. It will aid us in applicant evaluation as well. Please answer all questions as completely and truthfully as you can. You will not be approved or rejected as a placement solely on the basis of your answers. A Lily Rock Belgians representative will call you to discuss your application in greater detail.

Please complete the application below. Click on "Submit Form" to sent the application and "Clear Form" to start over.

APPLICANT INFORMATION
Name(s)
Complete Street Address

Home Telephone (including area code)

Business Telephone (including area code)

Complete Email Address  

Number of Adults Living in Household  

Occupation and Employer
(for all adults in household)

Number of Children Living in Household and Their Ages:

Who will be responsible for the care and training of the dog?

Would you prefer a Male or Female Belgian?
Male  Female  Does Not Matter

Which Variety of Belgian would you prefer?
Malinois  Sheepdog  Tervuren  Laekenois  Does Not Matter

HOME

Is your home a:
Single Family Home?  Townhouse/Condo?  Apartment?  Other?

If you chose OTHER, please explain

If you rent or lease, you must have written permission from you Landlord. Below, please give us your Landlord's complete name, address and telephone number:

Is your yard fenced?: Yes  No

If yes, note the approximate size of the fenced area, height and type of fencing material. If no, please explain how and where you will exercise a dog and allow it to relieve itself:

LIFESTYLE

How would you describe your household activity level:
Very Quiet?  Rather easy going?  Usually something going on?
Lots of Activities?

Is someone normally home during the day?: Yes  No

If not, how many hours will the dog be alone on a normal weekday?

How would you describe your household activity level?
Loose Indoors  Basement  Crate  Garage  Fenced Yard
Kennel Run  Loose Outdoors  Tied-up Outdoors  Other

If you chose OTHER, please explain

Where will the dog sleep?

If you travel frequently, who will care for the dog while you are away?

Are you willing to modify your daily schedule to accomodate a dog's needs, such as going outdoors in a fenced area or walking on a leash to perform bodily functions at least four times a day?: Yes  No

Are you willing to keep a collar with a tag bearing your name, address and phone number on your dog at all times?: Yes  No

Would you tattoo or microchip your dog?: Yes  No

In addition to regular life at home, would your Belgian:

Walk routinely with a family member?: Yes  No

Attend obedience, agility or herding classes?: Yes  No

Compete in Obedience, Agility or Herding Trials?: Yes  No

Travel with you?: Yes  No

Go to your place of business?: Yes  No

Be a playmate for your children or other pets?: Yes  No

PET HISTORY

Do you currently own one or more dogs?: Yes  No

If yes, please list the dog's names, sex and ages:

How many dogs have you owned in the past ten years?

Please list each dog's name, breed, age, how long owned by you and why you no longer own him/her:

Please list any other pets you have:

Have you ever bred or raised dogs?: Yes  No

Have you ever trained one or more dogs?: Yes  No

Are you familiar with crate training?: Yes  No

If no, would you be willing to learn more about it and consider the use of a crate (portable cage) as a training and transitional aid?: Yes  No

REFERENCES

Veterinarian -
Please list your Veterinarian and/or Clinic name, complete address and phone number below:

Personal Reference -
Please list name, complete address and phone number below:

I understand that in order to complete processing of this application, a visit to my home may be scheduled by a representative of the program, and that by submitting this application, I agree to such. I also certify that all information on this adoption application is true and correct. (Please type your full name below and this will serve as your signature)

Signature:

Signature:

Please use the space below for additional comments or information you would like to include to aid us in matching the right Belgian Shepherd with you and your family: