Dog Adoption Survey & Agreement

Thank you for visiting The Humane Society of Kitchener Waterloo & Stratford Perth and choosing to save a life! Please help us find a great canine match for you by filling out this adoption survey. We are excited to help you pick your new family member!

Name*

First NameLast Name

Partner's Name (if applicable)

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone*

Please enter a valid phone number.

Secondary Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Email*

example@example.com

Name:*

Animal ID #:*

Please note that you can find the Animal ID# on the animals profile page on our website. www.kwsphumane.ca

1. Are you 18 years of age or older?*

YesNo

2. What best describes your living environment?*

HouseTownhouseApartment/CondoOther

3. Do you currently rent or own?*

RentOwn

4. What best describes your household?*

A place with constant activity and noiseSometimes noisy/quietQuiet and calm most of the time

5. Tell us why you would like to adopt a dog:*

6. Tell us about the members of your household (please include ages):*

7. Tell us about any children that regularly visit your household:*

8. Tell us about any pets in your household (please include species, breed, age):*

9. Tell us about your lifestyle and any canine personality traits you are looking for:*

10. Tell us about any canine experience you have:*

11. When you are not at home, your dog will be:*

12. When you are at home, your dog will be: (Choose one)*

13. Tell us about any time away from the home (work and/or travel) and how care and enrichment would be provided during this time:*

14. Your dog will on average be alone for blanks* hours per day.

15. You have training experience with: (Select all that apply.)*

16. Please describe your approach to training (including any methods or tools):*

17. How would you address unwanted behaviours if they present in your home after adoption?*

18. Are there any behaviours you are willing to work on (i.e. resource guarding, separation anxiety, reactivity)?*

19. If you have other pets in the home, how do you plan to introduce your new dog to your resident pets?*

20. Your current veterinary clinic is:*

21. Is there anything else you would like us to know?*

22. Is there anything you would like more information about (i.e. training, basic care, medical care)?*

23. Please note that we are NOT a peanut free facility (we use peanut butter for dogs on site). If you have peanut allergies, please let us know your severity.

Where did you hear about us / this service / this program?*

Help us continue to improve our services by telling us what language you primarily speak at home:*

I acknowledge that:*

I am financially able to provide veterinary care, proper nutrition and any training this dog may needi have the time to provide training and enrichment for this dogOnly those selected for an animal will be contacted for a phone interviewI verify that all the above information is true and correct. I understand that if any information provided by me is false or inaccurate, I many not be eligible to adopt from The Kitchener Waterloo Humane Society now or at any time in the future

ANIMAL INFORMATION*

I Agree: (Please type in your initials at each statement if you have read and understood the following)

* 1. To provide proper and adequate food, water, housing, exercise, grooming and humane treatment at all times. To provide all required vaccinations and all necessary medical care as directed by a veterinarian. To obey local licensing and animal bylaws. Not to sell, give away or use this animal for experimental purposes, allow it to engage in dog fighting, train it or have it trained to attack other persons or animals.

I Acknowledge that: (Please type in your initials at each statement if you have ready and understood the following)

* 1. I am aware that a veterinarian has examined this animal, that is has been vaccinated, treated with a parasite prevention medication (that treats fleas, roundworms, hookworms, ticks and whipworms), has been microchipped and sterilized. I am aware that this animal has been vaccinated against Rabies, if older than 16 weeks and that this vaccine is only good for one year, unless advised otherwise.

* 2. I am aware that a veterinarian has examined this animal, that is has been vaccinated, treated with a parasite prevention medication (that treats fleas, roundworms, hookworms, ticks and whipworms), has been microchipped, sterilized and tested for heartworm. I am aware that this animal has been vaccinated against Rabies, if older then 16 weeks and that this vaccine is only good for one year, unless advised otherwise.

* 3. I am aware that pets may exhibit normal but potentially undesirable behaviours including, but not limited to, aggression, house soiling, biting, chewing (people furniture and woodwork), barking, digging, mounting people's legs, urine marking and that these normal behaviour patterns may be difficult to manage. No one at the Kitchener Waterloo Humane Society (KWHS) has told me that this pet will not engage in any of these behaviour patterns.

* 4. I have been informed that I should make an appointment with my veterinarian for a post adoption exam within 48 hours of adoption and that it is recommended to keep my adopted pet away from my current animal(s) until they have been examined by my veterinarian.

* 5. I understand that if my pet is diagnosed with an illness by a qualified veterinarian within the first 48 hours following it's adoption and I am not prepared to take responsibility for cost of medical care, I may return the animal to the KWHS. If I have authorized medical treatment within the first 48 hours, I am fully responsible for all costs. If I wish to adopt another animal, I may discuss this with Management If I do not wish to adopt another animal at time of return, a gift certificate can be issued for a future adoption. I understand that a refund, minus an administrative fee (dependent upon adoption fee), may be available.

* 6. I understand that any animal deemed good with children means that to the knowledge of the KWHS the animal has not shown aggressive behaviour and is likely to be compatible with children. I agree this is not a guarantee of a child's safety with this animal and that an adult should always supervise interactions between animals and children.

* 7. All people, including adults and children, who will be living with this animal will meet this animal at the scheduled adoption appointment. If this animal is returned due to allergies, or there is incompatability with household members, there will be no refund.

* 8. I understand that due to high veterinary costs, the KWHS does not do routine bloodwork, urine or fecal testing on their animals, and that these tests are only completed if symptoms warrant further investigation. This includes but is not limited to CBC and biochemisty panels.

* 9. I understand that should my pet not get along with any pet in my home that I may return the animal to the KWHS and will not receive a refund. Should I wish to adopt another pet, I can do so for the regular fee. I understand that the Humane Society cannot guarantee/predict or control the behaviour of my adopted pet or that of my current pet(s) in my home.

* 10. The KWHS is not responsible for any damage which the animal may inflict on another person, another animal, my property or the property of another and no attempt will be made by me to hold the KWHS responsible for any damage.

* 11. I am aware of the average costs to feed, train and provide veterinary care for a dog and I understand the financial obligations of owning this animal.

* 12. I accept the animal as it is at the time of adoption and understand that the KWHS is not responsible for any medical or behavioural conditions not readily detected or detectable prior to or at the time of this adoption or discovered after such adoption. At no time will the KWHS accept responsibility for expenses incurred following adoption for veterinary care or the services of an animal behaviourist. This includes veterinary expenses for animals currently residing in the home and animals owned by others.

* 13. I acknowledge that I have not had a cough, sore throat or trouble breathing in the last 10 days. That I have not been exposed to someone known to have or potentially have symptoms of COVID-19 in the last 10 days.

* 14. I acknowledge that I have read and understand this agreement and hereby release the KWHS from any present or future liability associated with my adoption of this animal.

I give permission for KWHS to release my contact information to Petsecure Adoptsecure program to receive my 6-week trial of pet insurance.

YesNo

I am prepared to adopt/take home the animal mentioned above on the day of my adoption appointment (possibly within 24-72 hours after submitting my adoption survey and agreement) if I am approved.*

YesNo

Yes, I would like to receive emails from The Humane Society of Kitchener Waterloo & Stratford Perth, 250 Riverbend Drive, Kitchener, Ontario, Canada N2B 2E9. Website: kwsphumane.ca. Phone: 519-745-5615. I understand that I can unsubscribe at any time using the unsubscribe button found at the bottom of every email.*

YesNo

I agree to receive a complimentary ROYAL CANIN Adoption recommendation kit (if available) as well as newsletters and other commercial electronic messages from Royal Canin Canada Company. By agreeing to receive Royal Canin communications - I am helping to feed the dogs and cats in the care of the Kitchener Waterloo Humane Society. I may withdraw my consent at any time using the unsubscribe mechanism provided to me in communications from Royal Canin. I may also contact Royal Canin at: Royal Canin Canada, 100 Beiber Rd., Puslinch, ON N0B 2J0 Tel. 1.800.527.2673Email: consumeraffairscanada@royalcanin.ca*

YesNo

I permit the Humane Society of Kitchener Waterloo & Stratford Perth Humane to use any photograph(s) taken of me with the pet I have adopted in newsletters, brochures, websites, or any other media

YesNo

Signature of Applicant*

Clear

Date

SIGNATURE OF HSKWSP STAFF:

DATE:

___________________________________________

_______________

The Kitchener Waterloo Humane Society at no time will sell, lend or give your personal information to any group or person. This includes List Brokers, Mail Order Businesses, Telemarketers or other companies who would sell their services or products. All information is stored in a secure manner in accordance with the Persnal Information Protection and Electronic Docuents Act.

Dog Adoption Survey

OWNER INFORMATION

Animal Information

Dog Adoption Agreement