Creekside Rescue Family Profile

Family Profile

Creekside Animal Rescue, Inc.
11791 North County Road 800 E
Roachdale, Indiana 46172 USA
www.creeksiderescue.org
CreeksideRescue@gmail.com
317.946.1316
Pet Info *
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Number of adults? *
Number of children? *
Ages? *
Is anyone in family allergic to animals? Yes No*
Employer: *
Landlord Name or Mortgage Co: *
Type of Residence: (Check all that apply) Own Rent House Condo Apartment*
Does your residence have any of the following? (Check all that apply) *

Yard Fence Dog Run Dog Door
Type of companion animal you are seeking? (Check all that apply) *

Puppy Adult Dog Kitten Adult Cat Other
Why are you interested in adopting a new pet? (Check all that apply) *

For myself For family For child For pet For protection For gift Other
Please list all current and previous pets owned in last 5 years.
Do you intend for your adopted pet to be an indoor or outdoor pet?
Indoor    Outdoor    Both
What is the longest duration you will leave your pet alone?   *
What's the longest duration you'll leave your pet unattended outside?*
If adopting a kitten/cat, do you plan on declawing? *If intending to declaw, we respectfully ask you NOT to adopt one of our kittens/cats as we believe it is an inhumane procedure.*

Yes No
Personal References: Please provide one *

Name Phone Number
Veterinarian: Name and Phone or Address *

Name Phone or Address
Signature *

By signing above, I agree that all information provided is accurate and current. Clear
Date *

Month Day Year
C.A.R. Representative
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