Please print, complete and return
Dog’s Name:
ID Number:
Breed:
Color:
Age:
Sex:
Adopter’s Name:
Adopter’s Address:
Adopter’s Phone Number:
Cell Number:
Email Address:
Employment Information:
Spouse’s Name:
Spouses Employer’s Name & Address:
Do you live in a: House ___ Apartment ___ Mobile___
Do you own or rent:
If you rent are you allowed to have a pet under your lease:
If a pet deposit is required, are you willing to put it up before bringing this animal home:
How long have you lived at this residence:
Do you have a fenced area for the dog:
If yes, what type of area (size):
Will the dog live primarily inside or outside:
Do you understand that all senior dogs and special needs dogs adopted through Second Hand Seniors must be housed inside the house 100% of the time? _______ Do you agree to abide by these terms and conditions? ______
Do you understand that senior dogs and special needs dogs adopted through Second Hand Seniors must be supervised whenever outside? Do you agree to abide by these terms and conditions? ________
Do you have a sturdy dog house for the dog:
Please list all household members and ages:
Do you agree to provide all medical needs for the dog through a licensed vet:
Do you agree to provide fresh food and fresh water daily for the dog you adopt:
We do not allow our rescue dogs to be tied, staked or chained in any manner.
Do you agree NOT to stake, tie or chain this dog:
If you adopt this dog, do you understand that the dog must wear a collar with a current ID tag at all times:
If for ANY reason you cannot keep the dog, do you agree to return the dog to Second Hand Seniors:
Do you agree to phone calls to check on the welfare of the dog:
Do you agree to scheduled home visits to check on the welfare of the dog:
Is anyone in the household allergic to animals:
What other animals do you currently own:
(Please give name, breed, sex and ages)
Are these animals kept inside or outside your home:
Are any of your current animals dog aggressive, toy aggressive or food aggressive:
Explain:
If a fight breaks out between your animals - do you have a safe and separate area for confinement?
Please describe:
Have you ever had a dog euthanized:
If yes, please give reason:
Have you ever had a dog get run over:
If yes, please explain
Have you ever had a dog get poisoned:
If yes, please explain
If you will be renaming this pet - list new name:
In order to keep paperwork straight we only allow the animal to be renamed once. Do you understand the animal must be listed as ______________ on all future paperwork including vet documents?
Are you willing to allow a scheduled home inspection before placement is made:
Please provide a vet reference (include clinic name, address and phone number):
NO LOW COST CLINICS - A REGULAR FULL SERVICE VET REFERENCE IS REQUIRED.
Have you ever been charged with or convicted of animal cruelty or animal neglect:
Has anyone in your household been charged with animal cruelty or animal neglect:
Terms & Conditions for Adoption: (Please Read & Initial)
Second Hand Seniors does not guarantee the health of any animal. The majority of our animals are from shelters. Sometimes animals are carrying diseases that cannot be detected during their stay with us. We encourage all adopters to take their pet to their vet for a complete health check. ______
Second Hand Seniors reserves the right to refuse placement of any animal for ANY reason. ______
I understand that if for ANY reason I am unable to keep my pet, I must return him/her to Second Hand Seniors. __________
I understand and agree that I must not engage this dog or any other dog in dog fighting. ________
I understand that I must provide fresh food, fresh water and sturdy shelter for this dog at all times. _______
I agree NOT to have this dog euthanized unless it is medically needed AND I have exhausted all treatment options AND have obtained a second opinion from a licensed veterinary AND have contacted Second Hand Seniors prior to euthanasia and received Second Hand Seniors consent to euthanize this animal. ______
I agree NOT to have this dog euthanized for any type behavioral issue. If a serious behavioral issue arises, I understand that I must inform Second Hand Seniors immediately. _______
I understand that Second Hand Seniors has the right to seize the dog if it believes the dog has been abused, neglected or abandoned (this applies for the lifetime of the animal) or I fail to comply with the terms and conditions of this adoption. ______
I agree to provide all medical needs for this dog. ________
I understand that I am not allowed to re-home (give away) my dog. _______
I understand that I may not surrender my dog to any animal shelter. _______
I understand that if my dog is impounded for any reason, I must contact Second Hand Seniors on the day of impound. _________
I understand that if the dog is missing or injured I must contact Second Hand Seniors immediately. ________
I understand that dogs bark, chew, tear up items, can bite and may have house training issues. I agree not to hold Pound Pals liable for any injuries or damages that may arise from this adoption/placement. _______
I understand that it is my responsibility to research breeds of dogs and choose the dog that best fits my lifestyle. _______
I certify that the information provided in this application is true and correct and that I agree to all terms and conditions stated. Any breech of this contract authorizes Second Hand Seniors to take immediate possession of the dog. I understand that Adoption Fees Are Not Refundable. ________
If for any reason this adoption/placement does not work out at any time, I understand that I must notify Second Hand Seniors as soon as I realize there is a problem. I agree to give adequate time for placement arrangements to be made. I understand adequate time under this agreement is defined as 30 days notice. (Note: House foreclosures are foreseeable and the 30 day notice applies). _______
If you cannot or will not continue to house the pet for the 30 day period, you must make a reservation, provide transportation to the boarding facility and PAY for the pet's boarding fees at Waggin Tails
http://www.waggintailsdaycare.com/ Our rescue rate is currently $10 per night which is a significantly reduced rate. If you refuse to honor the contract, we will board the animal if necessary and we will takes any needed steps to recoup the money from you.
In the event that I must return this pet, I understand that I must pay for boarding fees if I cannot or will not house the pet until other placement can be found or until 30 days has passed from the date Second Hand Seniors received written notice to pick the pet up? _______
I understand that I am not allowed to hit or strike this animal in any manner. _______
I understand that I must not muzzle, chain, stake, tether or bind this animal. ______
I may not kennel or crate this animal for long periods of time. _______
I understand this animal must live in sanitary conditions and that I must not allow him to live in a confined area in his own waste or the waste of any other animal or human. _____
I understand that Second Hand Seniors supports spaying and neutering when combined with common sense. SHS supports spaying and neutering of healthy pets of breeding age. However, since the majority of our pets are significantly aged, Second Hand Seniors evaluates each senior and special needs pet's health and decides if the benefit of spay/neuter outweighs the risk of surgery. I understand that this is soley Second Hand Seniors decision. _______
I understand that there are risk involved when deciding to adopt a pet. I am entering into this adoption agreement of my own free will and I agree to assume all responsibility for any losses, damages or liabilities resulting from this agreement. _______
I agree not to allow my children to harass, annoy, irritate or aggravate this dog. I certify that none of my children have harmed any animal. I understand that it is my responsibility to supervise my children while they are interacting with this pet. _______
I understand that this contract remains in effect for the lifetime of the pet. _____
I must report address and/or phone number changes to Second Hand Seniors within 30 days. ______
I understand that Second Hand Seniors microchips the majority of the pets they adopt out. I understand that the microchip is registered to Second Hand Seniors and that I am not authorized to change the registration. _____
**If your pet is lost and you have failed to keep your contact information updated, we may be unable to return your adopted pet. It is very important to keep your contact information updated and correct**
I understand that Second Hand Seniors reserves the right to refuse any application for any reason______
I understand that I must keep this pet on monthly heartworm preventative_____
I understand that Second Hand Seniors does not allow cosmetic surgery (ear cropping, tail docking, etc.) _____
I authorize Second Hand Seniors to contact my vet. ______
I agree and consent to a criminal background check. ______
I understand that an electronic version of this agreement is as legally binding as the original document. ______
I understand that I am making a lifetime commitment by choosing to adopt this pet. Second Hand Seniors expects adopters to provide a loving forever home even during times of the pet's illness. If you can no longer provide a safe and loving home, you must return the pet to Second Hand Seniors, give a minimum of 30 days written return notice and pay a relinquishment fee of $100. _______
All adults in your household must agree to the terms and conditions of adoption. Every household member over age 18 must agree with the terms and conditions of adoption, must sign this adoption agreement and provide his/her Driver's License information.
_________________________
Signature
________________________
Date
_________________________________
Driver’s License Number & Issuing State
SWORN AND SUBSCRIBED to me this _________ day of ____________________, 2010.
__________________________________________
Notary Public State of Texas
