Dog Adoption Form Dog Adoption Form Please fill out the following information if you are interested in adopting a dog. Date Submitted* MM DD YYYY Name of Dog*How did you hear about us?Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence*Phone*Format 555-555-5555Email How would you like us to contact you?* Email Phone Call Text Message Home InformationDo you own your home?* Yes No If renting, landowner'sLandowner Name* First Last Landowner's Phone*Do you plan to move in the near future?* Yes No Number of Adults in your Household:*Number of Children in your Household*Do you Currently Have Pets?* Yes No If Yes, How Many?Dogs:Cats:Other, list type and how many:Are they spayed/neutered?* Yes No Why aren't your current pets spayed/neutered?Are they up to date on all vaccinations?* Yes No Why aren't your current pets up to date on vaccinations?Your Vet's Name:*Your Vet's Phone Number:List any pets that you have had within the last three years and no longer have: (Type & Reason)Adopted Dog EnvironmentDo you agree to allow a home visit from a Safe Home Rescue representative prior to adoption? This will allow us to ensure the dog is the right fit for your home.How will the dog be cared for when you go on vacation?*How long will the dog be left home alone each day?*Where will the dog be spending most of his/her time when you cannot supervise him/her?*Where will the dog be spending most of his/her time when you are at home?*Where will the dog be spending most of his/her time when you are sleeping?*Do you have a fenced yard?* Yes No If not, how will you provide safe and adequate availability to the outside for exercise and housetraining?*How do you plan to housetrain the dog?*How long do you think it will take before he/she does not have accidents in the house?*How long will the dog spend alone outside each day?*Additonal CommentsAdopter Agrees All information provided is accurate to the best of his/her knowledge. He/she is 18 years or older. To provide shelter, fresh water, proper food and adequate companionship at all times. The dog will be kept primarily indoors and proper restraint will be used when outside. To provide annual veterinary examination, heartworm preventative, rabies according to the state’s regulations, and flea prevention as needed. To provide medication, vaccinations, and dental care as determined by adopter’s veterinarian. To arrange with Safe Home Rescue for sterilization procedure if the dog is too young to sterilize at the time of adoption. To follow positive reinforcement training methods. To notify Safe Home Rescue if for any reason adopter is unable to keep this dog, in order to find an appropriate home. A refund of the adoption fee will be provided within 30 days of adoption, the adoption fee will not be refunded after 30 days. Transfer of ownership of this pet is strictly prohibited without prior written authorization of Safe Home Rescue. The dog will not be euthanized in a non-emergency situation without notifying Safe Home Rescue and giving 3 days to respond.RELEASE OF LIABILITY AND INDEMNIFICATION Adopter promises and agrees to be solely responsible for this animal and to indemnify and hold harmless Safe Home Rescue from any and all claims of liability for the conduct of the pet on or after the date of this adoption and agreement of contract.Checking this box below indicates your acceptance to the terms stated above.* I Agree This iframe contains the logic required to handle Ajax powered Gravity Forms.