Humane Society of the Palouse
Please
give careful consideration to the responsibility you assume when adopting a
companion animal. It is a commitment,
which could extend over the next 10 YEARS OR MORE. Be sure your lifestyle allows the time,
patience, and expense needed to care for the animal that, as a member of the
family, will be dependent upon you for all of their needs.
WE
RESERVE THE RIGHT TO DENY ANY ADOPTION WE FEEL UNSUITABLE.
*You must be at least 18 years of age, with proof of age
and current address
*You understand that the adoption
amount is non-refundable
*You understand that any false information given during the
adoption process will result in a nullification of the agreement.
Animal information: HSOP #_______
Dog’s name:__________________sex:________ Breed:___________________
Description:_________________________________________
age:__________ Household information:
Adopter(s)_________________________________________________________
Physical Address______________________
city_____________State _________ zip__________
Mailing
Address_______________________city_____________State__________ zip__________
Phone number:
home______________ ____ work________________ other_________________
Housing (circle all that apply): own / rent / live with parents
house / condo / apt /
mobile
Landlord name:______________________
phone #:______________________
Length of time at this address:________
Others living at this address (including children and their
ages):___________________________
Is anyone home during the day?__________
Where will your new dog spend its days?(Circle
all that apply) Indoor/ Outdoor/ Basement/ Kitchen
Garage / Porch / Shut in room
Where
will your new dog spend its nights?(Circle all that
apply) Indoor/ Outdoor/ Basement/ Kitchen Garage / Porch / Shut in room
Is your yard fenced? _________ On
all sides? _________ Height: _________
Will you chain you dog?________
How many hours per day?___________
Will you use your dog as a guard animal?________
What provisions will you make for your dog when you go on
vacation?______________________
What behavior problems have you experienced with companion
animals in the past and how did you resolve them?________________________________________________________________
If you could no longer care for your dog what would you do?________________
Do you have any animals now? _______Species:_______ Sex:_____ Fixed_____ Age:___
Species:________
Sex:____ Fixed_____ Age:___
Species:________
Sex:____ Fixed_____ Age:___
Species:________
Sex:____ Fixed_____ Age:___
Who is your veterinarian?_______________________
phone #:______________
Have you gotten rid of any animals within the last
year? __________
Please describe circumstances?________________________________________
IMPORTANT!!!! READ BEFORE SIGNING:
____ 1. I agree to
provide proper food, water, adequate shelter and kind treatment at all
times. I will not mutilate or make any
permanent physical alterations of the dog for cosmetic or human convenience
purposes.
____ 2. I agree to take the animal to a veterinarian
for routine examinations and immunizations as needed; and to procure immediate
veterinary care, at my own expense, should the animal become ill or injured.
____ 3. The Humane Society of the Palouse, Inc has a
seven-day health guarantee on all dogs adopted from our shelter. You must contact the shelter before receiving
veterinary care. You must take your new
pet to the veterinary hospital used by the Humane Society of the Palouse to
have any medical bills paid for.
____ 4. The
Humane Society of the Palouse, Inc retains ownership rights during the
seven-day foster period. Therefore,
shelter staff must clear any medical decisions in regards to this animal and
the clinic used by the Humane Society of the Palouse.
____ 5. I agree to license the animal in compliance
with the laws and ordinances in force in the municipality in which I reside.
____ 6. I agree to notify the Humane Society of the
Palouse if I decide, at any time, that I can no longer take care of the
animal. I agree to not turn over the dog
to another party without the prior approval of HSOP.
____ 7. I agree not to allow the animal to be used
for medical or other experimental purposes.
____ 8. I understand that HSOP cannot guarantee the
health, temperament or training of the above described animal, although, to the
best of their knowledge the animal is healthy and adoptable.
____ 9. I agree to release HSOP from all liability
once the animal is in my possession and realize that the shelter will not be
responsible for it’s behavior or be liable for any
property damage or personal injury which the animal may cause. I understand that it may be in my best
interest to train the dog myself, and that any
negative behavior issues the animal has are my responsibility
____ 10. I acknowledge that in the event of any breach
of this contract, HSOP will be entitled to all reimbursements available under
this contract and
____ 11. I agree to notify the HSOP if there is a
behavior problem that arises and I feel that the animal needs to be
euthanized. HSOP reserve the right to do
our own evaluation of the animal before euthanasia takes place.
_____ 12. I have
read this entire section and have had it explained to me and I completely
understand and accept the rights and obligations involved. I hereby acknowledge
receipt of the above-described animal and understand that it is not a selling
price but a donation in exchange for medical and husbandry services provided by
HSOP.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND
UNDERSTOOD THIS CONTRACT AND AGREE TO COMPLY WITH ALL CONTRACT PROVISIONS. I HAVE RECEIVED A COPY OF THIS
CONTRACT FOR MY RECORDS.
Signature(s)_______________________________ date:__________
Approved
by Staff:__________________________ date: __________