Name       
Address  
City                State           Zip Code
Phone:     
E-mail:      

Name of rabbit(s) you are interested in adopting:    
How long have you been thinking about adopting a rabbit?    

Why do you want to adopt a rabbit?

How many of each in your household?
Adults:    Children:    Children ages?

For whom is this rabbit being adopted?  
Name of primary caretaker    
Primary caretaker   Adult Child     If child, enter age  

What research or reading have you done and what experience have you had with companion rabbits?

Are you interested in educational materials regarding houserabbits? Yes No

Please list other pets you've had, past and present (list current animals first).

Type of Animal	Age	Sex	Altered	If you no longer have the animal, please tell what happened.
		M F	Yes No
		M F	Yes No
		M F	Yes No
		M F	Yes No
		M F	Yes No
		M F	Yes No

Veterinarian Name and Vet Clinic:

What do you expect to spend for veterinary services each year for your rabbit(s)?

Plans for housing   Inside Outside
Describe living area size, location, etc.

Would you like assistance in planning your rabbit's housing? Yes No

Do you currently own or rent?
If renting, what pets does your landlord allow?

Landlord phone number  
Landlord address  

If you move, what will you do with your rabbit(s)?

Name some reasons that may cause you to give up your rabbit:

What pet behaviors are unacceptable in your home?

Is there anyone in your family who is allergic to rabbits or hay? Yes No

Under what circumstances, if any, will you rabbit be allowed outdoors?

If your rabbit is allowed outdoors, how will you protect the rabbit from escape and from predators (raccoons, hawks, cats, dogs, people, etc.)?