Adoption Application

Adoption Application
Name*

First Name & Middle NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Name of the dog that you are interested in:*
HouseApartmentCondoOther
RentOwnOther
How long have you lived at your current residence?*
If you are not the property owner, we will need to verify your landlord’s current pet policy.
Landlord's Name:

First NameLast Name
Landlord's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
How many adults live in your home? *
Information about all other persons living in your household:
First Name*   Last Name*   Age*   Relationship*
First Name   Last Name   Age   Relationship
First Name   Last Name   Age   Relationship
First Name   Last Name   Age   Relationship
How many children? * Ages? *
DogCatNone
Who will primarily be responsible for the care of this dog?*
CompanionSearch & RescueGuard DogAgilityHuntingJoggingObedience TrainingWalking BuddyCouch Warmer
How many hours will the dog be alone each day?*
Where will the dog be kept when no one is home?*
Where will the dog be kept at night?*
YesNo
If so, how high is your fence?
Type of fence?
YesNoN/A
YesNoN/A
YesNoN/A
Veterinary Practice Name*
*Please Note that you will need to call and authorize them to speak with us*
Veterinarian's Phone#*
Please enter a valid phone number.Format: (000) 000-0000.
Personal References:
First Name*   Last Name*       Area Code        Phone Number*     Relationship

First Name*   Last Name*       Area Code          Phone Number*    Relationship

First Name*   Last Name*         Type a label       Phone Number*   Relationship
Under what circumstances would you NOT keep this dog?*
Please list all of the pets you have had in the last 7 years including current pets and those you no longer own:

Species/Name   Breed Age   Sex AlteredOwned How Long What Happened to Him/Her?

Species/Name   Breed Age Sex Altered
Owned How Long What Happened to Him/Her?

Species/Name  Breed Age Sex Altered
Owned How Long What Happened to Him/Her?

Species/Name  Breed Age Sex Altered Owned How Long What Happened to Him/Her?
High EnergyOudoorsy DogLap DogMellowAffectionateQuietGuard Dog
Strict, demanding (dog must learn and follow all commands)Moderate (encouraging of good behavior)Lenient, wishy-washy, easily coerced by the dog
HighMediumLow
RarelyOccasionallyDailyWeeklyMonthly
Would enjoy walking with me on leashWill exercise him/herself in our yardWould enjoy going to the dog parkWould run, jog or hike with meRequires only enough exercise to do his/her business
My ideal dog would:*
Bad dog habits that I cannot tolerate are:*
Please initial the following:
Signature*  I understand and agree that Kane’s Mission – Dog Rescue makes no express or implied warranty, representation or promise to the age, health, breed, habits, disposition or safety of the animal. I hereby accept the animal as is, assume all risks and responsibilities associated with the ownership of the Animal, including bites, and I hereby fully and completely release, indemnify and hold harmless Kane’s Mission – Dog Rescue, its directors, officers, volunteers, and employees from any claim, cause of action or liability of any sort or nature, whether known or unknown, directly or indirectly arising out of or in connection with the adoption, care or ownership, maintenance, temperament or condition of the Animal.
Signature*   I agree in the case I cannot keep the animal, he/she will be returned to Kane’s Mission – Dog Rescue. All monies deposited with KMDR with be considered a donation to the rescue and are non-refundable.
Signature*   I have never been convicted of, or charged with, animal abuse, animal neglect, animal fighting, animal abandonment, or other animal related crime.
Signature*   I agree to allow KMDR to perform a criminal history background check.
Signature*   I acknowledge falsification of the above can result in my being denied adoption of an animal or if animal has been adopted to me, the return of that animal to Kane’s Mission – Dog Rescue.
Signature*   I certify that the above information is true and correct to the best of my knowledge.
Signature:   Signature*   Date:   Date*
Printed Name:   *
Should be Empty: