Small Animal 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 small animal 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? (Choose one)*

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 want to adopt a small animal:*

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

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

8. Tell us about your lifestyle and any small animal personality traits you are looking for:*

9. Tell us about any small animal experience you have:*

10. What size enclosure will your new small animal have and how will you set it up?

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

12. If you have other pets in the home, how do you plan to introduce your new small animal to your resident pets?

13. Did you know that most small animals need to be seen by a Veterinarian that specializes in small animals such as rabbits, birds, reptiles?

YesNo

14. Do you have a vet that you will take your new small animal to?

YesNo

15. Your current veterinary clinic is:*

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

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

18. 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? (Please select all that apply.)*

Help us continue to improve our service 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 small animal may need.I have the time to provide training and enrichment for this small animal.Only those selected for an animal may be contact for a phone interview.I verify that all the above information is true and correct. I understand that if any information provided by me is false or inaccurate, I may not be eligible to adopt from The Kitchener Waterloo Humane Society now or at any time in the future.

I hereby acknowledge receiving from the Kitchener Waterloo Humane Society (KWHS) a: (Choose one)*

ANIMAL INFORMATION*

The Animal ID Number can be found on the animal's profile on our website. www.kwsphumane.ca

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 animal by-laws. To not sell, give away or use this animal for experimental purposes.

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

* 1. I am aware that an RVT or veterinarian has examined this animal, that it has received a full physical assessment and that any found medical concerns have been treated.

* 2. I have been informed that all animals can from time to time carry and transmit diseases, some of which can affect people, including bacteria, viruses, parasites, and fungal diseases (i.e. ringworm) and that these diseases may be undetectable in what appears to be a healthy animal at the time of adoption.

* 3. I am aware that pets may exhibit normal but potentially undesirable behaviours including, but not limited to, aggression, house soiling, biting, scratching (people, furniture and woodwork), digging, urine spraying 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 its 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 with 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 that 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 consent to the adoption and at least one head of household will meet this animal at the scheduled adoption appointment. If this animal is returned due to allergies, or there is incompatibility 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.

* 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 KWHS 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 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 small animal 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 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 permit The Humane Society of Kitchener Waterloo & Stratford Perth 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. ((Use your mouse, touchpad, or touchscreen to add your signature.) *

Clear

Date*

Date

SIGNATURE OF HSKWSP STAFF/VOLUNTEER:

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.

Small Animal Adoption Survey

OWNER INFORMATION

Animal Information

Small Animal Adoption Agreement