MASA Adoption Application

How did you hear about Midland Animal Shelter Adoptables

What is the name of the animal you are interested in adopting?*

Full Name

First NameLast Name

Age

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Primary Phone Number*

Area CodePhone Number

Spouse or Emergency Contact's Name*

Spouse or Emergency Contact Phone Number*

Area CodePhone Number

Do you live in a house, apartment, or mobile home?*

Do you:*

OwnRentLive with ParentsOther

If Renting: Please provide landlord contact information

Describe your Homes Activity Level*

Busy/NoisyModerate Comings/GoingsQuiet with Occasional Guests

Please List all People Living in the Household (Include Name, Relationship, Gender and Age)*

Does Anyone in your Household have Allergies to Animals?*

YesNo

Are all members of your Family agreeable to adopting and animal?*

YesNo

Please List any Pets you have living in your home. (Please include Name, Breed, Age, Altered, See, UTD Vaccines, UTD on prevention, kept inside or outside)*

Would you be interested in fostering?

YesNoWould like more information

Please understand that new animals take time to adjust in new environments. How long would you be willing to give your new family member to adjust? Under what circumstances would you release the animal back to Midland Animal Shelter Adoptables?*

Do you currently have a Vet?*

YesNo

If yes, who?

We cannot guarantee a dog to be housebroken, are you equipped to train with love and patience?*

YesNo

Have you had any experience with with an emotionally or physically neglected or abused dog?*

YesNo

If Yes please explain

Are you willing to use a crate for a dog if recommended?*

YesNo

Do you have a fenced yard?*

YesNoPartial

If fenced, please give details on height, material, # of gates, are gates locked or lockable?

How many hours in a day would the adopted animal be left alone?*

Where will your new family member be kept during the day? At night? *

Vet Reference: Full Name*

NameClinic Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Please list 1 personal reference with names, addresses, phone numbers and how related. We prefer it not to be a relative.

Reference Full Name*

Relation to applicant(s):*

E-mail

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully. I understand that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application can result in the forfeiture of any Midland Animal Shelter Adoptables animal adopted by me. I certify that the above information is correct, and I understand that the information will be verified. I understand that by submitting this form electronically, I agree to release and covenant to hold harmless Midland Animal Shelter Adoptables and it's members from any claims, damages, costs, or actions incurred because of the care or actions of the adopted animal. I accept full responsibility for the animal(s) actions at all times, and release Midland Animal Shelter Adoptables and it's board members and/or volunteers from any liabilities or damages that may be incurred because of adopting such animal(s). I agree to have Midland Animal Shelter Adoptables complete reference call checks and conduct a home visit inspection to be able to approve my adoption application. I agree that if I'm unable to keep the animal(s) anymore that I will return the animal(s) to Midland Animal Shelter Adoptables and try to give Midland Animal Shelter Adoptables a 2 week period to try and find another suitable foster or home for the animal(s). Under no circumstances will I re-home the Midland Animal Shelter Adoptables animal myself. I agree that Midland Animal Shelter Adoptables has my permission to remove the animal from the applicant's premises if deemed necessary and agrees this entry shall not constitute as a tresspass. I understand that the adoption fee is considered a donation and is non-refundable. I understand that typically MASA does provide a behavioral assesment before placement, but cannot guarantee these behaviors once the animal is in a new home and, like humans, can react to each situation differently.

Date

MonthDayYear

Your name*

E-mail