Harmony Dog Rescue Adoption Application

Perspective Pet Parent*

First NameLast Name

Additional family member you would like to add to application:

First NameLast Name

Email Address*

example@example.com

Your age*

What is your occupation?*

Phone Number*

Alternate phone number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name of dog you would like to adopt: *

Please explain why you would like to adopt this dog. *

Are all members of the household in agreement in regards to adopting this pet*

YesNoUndecided/hesitant

Please list names and ages of all individuals currently living in your house. *

Do other pets live in your home?*

YesNo

Please list name, age and breed of each pet currently living in your house. *

What is/are your pet(s) disposition and behavior towards other dogs?*

Name of Veterinarian *

Veterinarian Phone Number*

Please enter a valid phone number.

Please indicate your living environment (choose only one)*

Do you own or rent?*

OwnRent

If you rent, what is your landlords pet policy?*

Landlords name and telephone number *

Name/business name

Do you have a yard?*

YesNo

Is your yard fenced? If so, please describe the fencing (material/height). *

Have you ever surrendered a pet you own to any animal shelter including a "low" or "no kill" shelter?*

YesNo

How many hours a day do you anticipate the dog will be left alone?*

Where will the dog stay in the home when alone on a typical day (ie in a crate, loose in the home, outside)?*

If you have to leave town, emergently or planned, where would your pet stay?*

Do you intend to provide a permanent home for the rest of the dogs life?*

How would you deal with behavioral issues such as barking, chewing, destructive behavior, bathroom accidents indoors, unruly leash behaviors in your pet?*

How many dogs have you had in the past 15 years? If you no longer have these dogs, can you explain why not (ie passed away, rehomed,etc). *

3 Personal References (Required)

Have you ever been convicted of an animal related crime, such as cruelty to animals, animal theft, or animal abandonment?*

YesNo

Please provide a detailed description:

By clicking the submit button, I agree to move forward with the adoption process, which could involve a home inspection, animal meet and greet and/or interview.

By clicking the submit button, I understand all my references may be checked including veterinary and personal.

By clicking the submit button, I understand there is an adoption donation associated with adoption of a pet and that it is tax deductible according to IRS 501(c)3 guidelines. I understand this donation will ensure that Harmony Dog Rescue (HDR) is equipped to provide care for another animal that needs fostered or adopted.

By clicking the submit button, I understand that if I no longer want or can no longer care for my adopted dog, I agree to notify HDR immediately by phone and may be required to keep the dog for up to seven days to allow HDR to find placement for the dog. I may be asked to transport the dog back to HDR.

By clicking the submit button, I agree to indemnify and hold harmless HDR against any losses, lawsuits, claims, injury, damages incurred by me or to any persons or property by my adopted dog, once adoption has been completed.

By clicking the submit button, I understand that HDR will disclose any of the pet's health or behavior issues before adoption is completed.

By clicking the submit button, I verify all of the above information is true and accurate.

Date

Signature of Potential Pet Parent