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TETON VALLEY HUMANE SOCIETY
DOG ADOPTION APPLICATION
Name of Dog(please print clearly)_________________________
Applicant
First Name ________________ Last Name ____________________
Age _____ Occupation _____________________________________
Co-applicant (Spouse or Significant Other)
First Name ________________ Last Name ____________________
Age ____ Occupation ______________________________________
Street Address
City ____________ County ____________ State ___ Zip ______
PO Box ____________ City ____________ State ___ Zip ______
Home Phone __________________ Work Phone _________________
Cell Phone __________________ E-mail _____________________
List any questions you would like to ask about this dog __
__________________________________________________________
__________________________________________________________
Are you willing to allow a representative from TVHS visit your home by appointment? Yes___ No___
Please check any of the following reasons for adopting this dog: family pet, child’s pet, watchdog, companion, hunting dog, guard dog, pet gift, other (please specify) __________________________________________________________
Please indicate where you live: apartment, house, condo, townhouse, mobile home.
Do you: rent home or own home?
If you rent, do you have the landlord’s permission to own a dog? Yes___ No___
What is the apartment complex name? ______________________
What is the landlord’s name? _____________________________ Phone ___________ How much is the pet deposit? ___________
How many times have you moved in the past 5 years? _______
If you move, will your pet go with you? Yes___ No___
Would you ever consider moving somewhere that doesn’t allow pets? Yes___ No___
Do you foresee any major changes in your life in the next 15 years (average life span of a dog) such as marriage, childbirth, health problems due to age, going away to college? Yes___ No___
If yes, please explain ___________________________________
Do you or anyone in your household currently have any serious health problems? Yes___ No___
If yes, please describe __________________________________
Can you provide a permanent home for this dog for 10-15 years? Yes___ No___
Do you have a fully fenced yard with no fence gaps? Yes___ No___ If yes, please specify (circle all that apply): Under 4ft, 4ft, 5ft, 6ft or higher, Chain link, Picket, Invisible, Privacy, Other.
If no, how will you handle exercise and toilet duties __________________________________________________________
Number of adults in household ____________________________
Relationship: spouse, roommate, life partner, other (please specify)__________________________________________
Does anyone in the household smoke? Yes___ No___
Do any children live in the house? Yes___ No___
If so, what are their genders/ages? __________________________________________________________
Number, type and age of pets currently in household_______
__________________________________________________________
Do any of your current or did any of your past pets live primarily outdoors? Yes___ No___ If yes, please describe pet ______________________________________________________
Were all previous pets or current pets spayed/neutered?
Yes___ No___
What is your veterinarian’s name and phone number?
__________________________________________________________
How many dogs have you owned in the past? ________________
If any, please check what happened to each of them: euthanized, run over, died of old age, sold, given away, ran away, medical condition.
Has a dog died on your premises in the last 6 months of distemper, parvo, or unknown causes? Yes___ No___
Have you always kept an ID tag (other than rabies) on your pet? Yes___ No___
Will you keep a collar and TVHS ID tag on all of your pets including your new dog at all times? Yes___ No___
How many hours will the dog be home alone on a typical day? ________
Where will your new dog stay when home alone during the day: outside, in dog pen, outside in fenced area, outside on chain or tie-out, loose outside, barn, inside basement, in the garage, loose inside, crate, other ________________
Where will the new dog sleep at night: dog house, fenced area, dog house in dog pen, dog house near tie-out, inside in basement, in the garage, inside the house, crate, on my bed.
What circumstances, in your mind, justify giving a dog up: moving, new baby, divorce, not getting along with other pets, getting out of fence, behavioral problems, children lost interest, if it gets to big, too time consuming, shedding, allergies, housebreaking problems, medical problems, aggressive, other ______________________________
If you are unable to keep your dog will you return the dog to us or notify us? Yes___ No___
Have your ever surrendered a dog to a shelter before? Yes___ No___
Have you ever adopted from TVHS before? Yes___ No___
How did you hear about TVHS: website, newspaper, friend, radio, special event, other ______________________________
Do you agree not give the animal to anyone else without prior notification to TVHS? Yes___ No___
If allowed to adopt a pet from TVHS I agree to do the following: yearly vaccinations,Rabies vaccinations, food & water, exercise, shelter, grooming, spay/neuter (if applicable) by this date _______________.
RELEASE
I accept the animal as is and assume all risks of its ownership, including the risk of injury or damage caused by the animal (such as animal bites). On behalf of myself, my heirs, personal representatives and assigns, I hereby release, discharge, indemnify and hold harmless the Teton Valley Humane Society and its directors, officers, employees, and agents from any and all claims, causes of action and demands of any nature, whether known or unknown, arising out of or in connection with my adoption.
By signing below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for disallowing the adoption of a TVHS dog and possible removal of an adopted dog from my home and fines up to $150.00 dollars. Applicant must be 18 years of age or older. Teton Valley Humane Society reserves the right to refuse any applicant.
_____________________________ ____________
(Signature) (Date)
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OFFICE USE ONLY
HOLD
FOSTER
ADOPTED
Has adoption form been completed and signed? Yes___ No___
Please include the following in adoption (check all that apply): Food, Toy, Medical paperwork, Adoption packet, Spay/Neuter Certificate, License, Teton County ID, Collar, Leash Tag #___________
Borrowed items __________________________________________________________
Cash
Check _________
Visa
Master Card
Amex
Discover
Money Order
_____________________________ ____________
(Employee Signature) (Date)