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TETON VALLEY HUMANE SOCIETY
DOG ADOPTION APPLICATION

Name of Dog(please print clearly)_________________________

Applicant
First Name ________________ Last Name ____________________
Age _____ Occupation _____________________________________

Co-applicant (Spouse or Significant Other)
First Name ________________ Last Name ____________________
Age ____ Occupation ______________________________________

Street Address
City ____________ County ____________ State ___ Zip ______
PO Box ____________ City ____________ State ___ Zip ______
Home Phone __________________ Work Phone _________________
Cell Phone __________________ E-mail _____________________


List any questions you would like to ask about this dog __
__________________________________________________________
__________________________________________________________

Are you willing to allow a representative from TVHS visit your home by appointment? Yes___ No___

Please check any of the following reasons for adopting this dog: family pet, child's pet, watchdog, companion, hunting dog, guard dog, pet gift, other (please specify) __________________________________________________________

Please indicate where you live: apartment, house, condo, townhouse, mobile home.

Do you: rent home or own home?
If you rent, do you have the landlord's permission to own a dog? Yes___ No___

What is the apartment complex name? ______________________
What is the landlord's name? _____________________________ Phone ___________ How much is the pet deposit? ___________

How many times have you moved in the past 5 years? _______

If you move, will your pet go with you? Yes___ No___

Would you ever consider moving somewhere that doesn't allow pets? Yes___ No___

Do you foresee any major changes in your life in the next 15 years (average life span of a dog) such as marriage, childbirth, health problems due to age, going away to college? Yes___ No___

If yes, please explain ___________________________________

Do you or anyone in your household currently have any serious health problems? Yes___ No___

If yes, please describe __________________________________

Can you provide a permanent home for this dog for 10-15 years? Yes___ No___

Do you have a fully fenced yard with no fence gaps? Yes___ No___ If yes, please specify (circle all that apply): Under 4ft, 4ft, 5ft, 6ft or higher, Chain link, Picket, Invisible, Privacy, Other.

If no, how will you handle exercise and toilet duties __________________________________________________________

Number of adults in household ____________________________
Relationship: spouse, roommate, life partner, other (please specify)__________________________________________

Does anyone in the household smoke? Yes___ No___

Do any children live in the house? Yes___ No___

If so, what are their genders/ages? __________________________________________________________

Number, type and age of pets currently in household_______
__________________________________________________________

Do any of your current or did any of your past pets live primarily outdoors? Yes___ No___ If yes, please describe pet ______________________________________________________

Were all previous pets or current pets spayed/neutered?
Yes___ No___

What is your veterinarian's name and phone number?
__________________________________________________________

How many dogs have you owned in the past? ________________
If any, please check what happened to each of them: euthanized, run over, died of old age, sold, given away, ran away, medical condition.

Has a dog died on your premises in the last 6 months of distemper, parvo, or unknown causes? Yes___ No___

Have you always kept an ID tag (other than rabies) on your pet? Yes___ No___

Will you keep a collar and TVHS ID tag on all of your pets including your new dog at all times? Yes___ No___

How many hours will the dog be home alone on a typical day? ________

Where will your new dog stay when home alone during the day: outside, in dog pen, outside in fenced area, outside on chain or tie-out, loose outside, barn, inside basement, in the garage, loose inside, crate, other ________________

Where will the new dog sleep at night: dog house, fenced area, dog house in dog pen, dog house near tie-out, inside in basement, in the garage, inside the house, crate, on my bed.

What circumstances, in your mind, justify giving a dog up: moving, new baby, divorce, not getting along with other pets, getting out of fence, behavioral problems, children lost interest, if it gets to big, too time consuming, shedding, allergies, housebreaking problems, medical problems, aggressive, other ______________________________

If you are unable to keep your dog will you return the dog to us or notify us? Yes___ No___

Have your ever surrendered a dog to a shelter before? Yes___ No___

Have you ever adopted from TVHS before? Yes___ No___

How did you hear about TVHS: website, newspaper, friend, radio, special event, other ______________________________

Do you agree not give the animal to anyone else without prior notification to TVHS? Yes___ No___

If allowed to adopt a pet from TVHS I agree to do the following: yearly vaccinations,Rabies vaccinations, food & water, exercise, shelter, grooming, spay/neuter (if applicable) by this date _______________.

RELEASE
I accept the animal as is and assume all risks of its ownership, including the risk of injury or damage caused by the animal (such as animal bites). On behalf of myself, my heirs, personal representatives and assigns, I hereby release, discharge, indemnify and hold harmless the Teton Valley Humane Society and its directors, officers, employees, and agents from any and all claims, causes of action and demands of any nature, whether known or unknown, arising out of or in connection with my adoption.

By signing below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for disallowing the adoption of a TVHS dog and possible removal of an adopted dog from my home and fines up to $150.00 dollars. Applicant must be 18 years of age or older. Teton Valley Humane Society reserves the right to refuse any applicant.

_____________________________      ____________
        (Signature)                   (Date)

==========================================================
OFFICE USE ONLY

HOLD
FOSTER
ADOPTED

Has adoption form been completed and signed? Yes___ No___

Please include the following in adoption (check all that apply): Food, Toy, Medical paperwork, Adoption packet, Spay/Neuter Certificate, License, Teton County ID, Collar, Leash Tag #___________

Borrowed items __________________________________________________________


Cash
Check _________
Visa
Master Card
Amex
Discover
Money Order

_____________________________     ____________
    (Employee Signature)              (Date)