Adoption Application Tibetan Spaniel Rescue Prospective Adopter Questionnaire The Prospective Adopter Questionnaire is the adoption application form for TSCA Rescue. You may submit the form when you are first added to the prospective adopter database (the "waiting list"), and we will keep it on file. Or, you may submit it later when you see a Tibbie that you want to adopt. Submitting it in advance can speed up the process when you want to adopt a Tibbie in our care. TSCA Rescue selects the forever home that’s the best match for each Tibbie in terms of family and lifestyle. In addition to reviewing your answers on the Questionnaire, the screening process involves reference checks and a home visit. For more information about the adoption process, see our Adoption page. Please give some thought to each question as you answer. If you need to stop before completing the Questionnaire, scroll to the end where you will find a Save and Continue button. When you press the Save and Continue button, you will receive a link so that you can return to your Questionnaire later. You can also opt to have the link sent to you by email. When you have finished answering all the questions, press the Submit button to send the form to us. If you missed a required question(s), you'll receive an error message. Scroll down through the form to find the errors in red. After correcting the errors, you must re-submit the form. If you made no errors, you'll see a confirmation message.If you need help, you can reach us at info@tstrust.org.General InformationYour Name(s):(Required) Are you interested in a specific Tibetan Spaniel that is currently available for adoption from TSCA Rescue?(Required)We notify people on our prospective adopter waiting list about available Tibbies via "Rescue Alert" emails. If you aren't already signed up when you submit this Questionnaire, we will add you to the waiting list and send you a "welcome email." Yes Not at this time. Please keep my application on file. Tibbie's Name(s):(Required) Are you at least 18 years old?(Required) Yes No Email:(Required) Cell Phone:Other Phone:Residence Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have another residence?(Required) Yes No Additional Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Profession: Please list the names and ages of all persons who live in your home, including yourself:(Required)Will children under 12 visit your home?(Required)NeverRarelySometimesOftenDogs and small children should be supervised. Can you provide supervision at all times? Yes No Do you or any family members have ongoing medical conditions or limitations (such as allergies) that may interfere with owning a dog?(Required) Yes No Please explain the condition:(Required) Your Pet OwnershipDo you currently own any dogs?(Required) Yes No How many?(Required)Please enter a number from 1 to 20.Current age(s):(Required) Age(s) when acquired: Breed(s):(Required) Gender(s):(Required) Are all the dogs you own spayed or neutered?(Required) Yes No Tell us about their temperament:(Required)For example, are they active or couch potatoes, quiet or barky, independent or obedient, timid or friendly?Have any of the dogs ever injured another dog or a person?(Required) Yes No Please describe what happened.(Required)Have you previously owned any pets?(Required) Yes No How many and what kind of pets?(Required)What happened to these pets?(Required)Do you have other pets?(Required) Yes No Tell us about each one:(Required)Please include type of pet, age, gender, when acquired, and temperament.Veterinary InformationThis is about the veterinarian or practice that cares for (or will care for) your pets.Veterinary Clinic Name:(Required)We will contact your veterinary practice for a reference check. Veterinarian: Veterinary Practice Address: Street Address City State / Province / Region ZIP / Postal Code Veterinarian Phone:(Required)Your HomeI live in a(n):(Required)HouseApartmentOtherDo you own or rent your home (check one)?(Required)OwnRentAre you allowed to have pets?(Required) Yes No Landlord Name: Describe your home:(Required) Do you have a safe and securely fenced yard with no holes or gaps in the fencing?(Required) Yes No How do you plan for the dog to relieve itself?How and when will the dog exercise?(Required)How many hours a day are you away from home on average?(Required)Where will the dog be when you are away from home?(Required)Please be specific. When you are away from home on vacation or extended periods, how will the dog be cared for?(Required) Where will the dog sleep?(Required) Are you willing to accept a dog that is not reliably house-trained?(Required) Yes No Coming to a new home sometimes disrupts house-training for a transition period. How would you deal with a break in training?(Required)Rescue dogs have often gone through bad experiences in their lives. When you first bring home a foster or adopted dog, the dog's stress and insecurity sometimes leads to less-than-perfect behavior, such as growling at other pets. The dog may need help to adjust to his new life. How do you feel about working with an experienced dog behaviorist or a force-free trainer who can help the dog adjust?(Required)Will you make sure that the dog receives the following routine care, even if you can't do it yourself: regular brushing and mat removal, occasional bathing, nail trimming, ear cleaning, teeth cleaning?(Required) Yes No Experience and PreferencesWhy do you want to adopt a dog at this time? How do your family members feel about it?(Required)Have you had any experience with adopting a rescue?(Required) Yes No Please tell us about your experience:(Required)Gender Preferred:(Required)MaleFemaleGender Doesn't MatterAge (in years) Preferred:(Required)Puppy (0-1)Teenager (1-3)Young Adult (4-5)Adult (6-10)Senior (11+)Age Doesn't MatterDo you understand that it isn't always possible to tell the age of a rescue?(Required) Yes No Why do you think a Tibetan Spaniel is a good fit for your personality and lifestyle?(Required)Are you willing to accept a dog that has treatable medical conditions such as those that require ear or eye drops, medicine or other treatments?(Required) Yes No Maybe If maybe, please explain:(Required)Additional comments about your preferences:Adoption ProcessDo you understand that filing this form does not guarantee that you will be selected to adopt a Tibbie?(Required)We select the home that is the best match for each individual Tibbie in terms of the Tibbie's needs and the family's lifestyle. Yes No Do you understand that a visit to your home is a required step in the adoption process?(Required)Home visits may be conducted in person or by computer. Yes No First Personal Reference Name:(Required)We ask for two personal references. First Personal Reference Relationship:(Required)Only one personal reference may be a relative. First Personal Reference Address: Street Address City State / Province / Region ZIP / Postal Code First Personal Reference Phone:(Required)First Personal Reference Email: Second Personal Reference Name:(Required) Second Personal Reference Relationship:(Required)Only one personal reference may be a relative. Second Personal Reference Address: Street Address City State / Province / Region ZIP / Postal Code Second Personal Reference Phone:(Required)Second Personal Reference Email: Do you understand that, if selected to adopt a Tibbie, you will be required to sign a contractual Adoption Agreement?(Required)The Agreement requires you to certify that you will take appropriate care of the Tibbie and that, if you are unable to keep the Tibbie for any reason or at any time, TSCA Rescue will re-home the Tibbie. Our commitment is for the life of the Tibbie. Yes No Do you understand that, if selected to adopt a Tibbie, a donation to the TSCA Rescue & Health Trust, a 501c3 non-profit, will be required to help defray the costs of rescue?(Required)Donation amounts are based on age and any special needs of the dog. A typical donation is $250. Yes No Do you understand that you may be responsible for transport-related costs?(Required)This may include, for example, a travel crate, cost of a medical certificate, fares or fees required by airlines or other modes of transport. Yes No Certain risks are inherent in handling dogs, and you must be willing to accept those risks. Do you agree that you will hold neither the Tibetan Spaniel Club of America, Inc. or its officers nor the TSCA Rescue & Health Trust or its trustees responsible for any loss, damage, injury, harm, claims, liability, costs and/or expenses of any nature whatsoever arising out of or in connection with adopting a rescue Tibetan Spaniel? Do you agree to this waiver of liability?(Required) I agree to this waiver of liability. Certification(Required)I/we hereby submit this information to TIBETAN SPANIEL CLUB OF AMERICA RESCUE in partnership with the TSCA RESCUE AND HEALTH TRUST (hereafter the "Rescue") with the intention of adopting a Tibetan Spaniel from the Rescue. I/We understand that, when selecting adopters, the Rescue is motivated solely by concern for and love of the Tibetan Spaniel breed, that they are acting as good Samaritans and that no TSCA member or Trustee profits from the adoption. I/We: 1. Do not own or have any interest in a pet shop or boarding kennel and that I/we are not engaged in buying dogs for resale. 2. Have never been convicted of cruelty to animals. 3. Have not been disciplined nor are under suspension by the American Kennel Club, Tibetan Spaniel Club of America, or any other purebred dog association or organization. I/We certify that all information given in this Prospective Adopter Questionnaire is true and correct.Your Signature:(Required)Enter (key) your name(s). Signature Date:(Required)Enter date you're submitting this form. Thank you for your interest in adopting a rescue Tibbie.