If you are not the property owner, we will need to verify your landlord’s current pet policy.
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? *
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
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 AlteredOwned How Long What Happened to Him/Her?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?
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: *