It Takes A Village Non-profit Rescue

Dog/Puppy Adoption Application
Date
/ Month / Day Year
Dog's Name of Interest:
Breed and/or Description
How did you learn about this dog?
We are happy that you have come to us to adopt a dog/puppy. To help ensure that the animal you want will be best suited to you, your home and lifestyle and that the animal will be placed in an environment compatible with its needs, we ask for your cooperation in filling out this application. We hope you will agree that the animal's welfare MUST be our foremost consideration. Thank You!
Name:
First Name Last Name

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone:
- Area Code Phone Number
Cell Phone:
- Area Code Phone Number
Work Phone:
- Area Code Phone Number
Name(s) of other adults in the household:
Email Address:
Place of Employment:
Who will be responsible for this animal?
What kind of home do you live in (i.e. House, Apartment, Duplex, Mobile Home)?
Do you: Own, Rent, Live with parents,relative or guardian, Other?
If renting, does your landlord/rental agency allow pets?
Landlord's Name:
Landlord's Phone Number:
How long have you lived at your present address?
How many times have you moved in the last 5 years?
Do you anticipate moving in the next year?
Can you commit to caring for a pet for its lifetime?
Have you ever given up a pet? If so, why?
What do you think is a reasonable amount of time for a dog to adjust to a new home?

48 hours 1 week 1 month 6 months other
If you selected "Other" to the above question, please explain.
Are you willing to allow for this adjustment period?

Yes No, I perfer a pet who will adjust quickly No sure
What experience do you have with the breed of dog (or similar breed of dog) you are applying for?
Do you have children at home? Ages?
Are they used to animals?
Is anyone in the household allergic to animals?
Do all adult members of the household know that you plan to adopt a dog?
Describe your household activity level/noise level:
Tell us about the pets you currently own:
Pet #1
Type of Animal:
Age and Sex of Animal:
Is the animal spayed/neutered?
Personality:
This animal was last vaccinated when ?
If your pet is a dog or cat, how often are they given heartworm preventative?
Is this animal ever on flea preventative? If so, what brand?
Pet #2
Type of Animal:
Age and Sex of Animal:
Is the animal spayed/neutered?
Personality:
This animal was last vaccinated when?
If your pet is a dog or cat, how often are they given heartworm preventive?
Is this animal ever on flea preventive? If so what brand?
Pet #3
Type of Animal:
Age and Sex of Animal:
Is the animal spayed/neutered?
Personality:
This animal was last vaccinated when?
If your pet is a dog or cat, how often are they given heartworm preventive?
Is this animal ever on flea preventive? If so what brand?
How do you plan to exercise your new dog/puppy? How often?
What is the name and address of your current veterinary clinic?
Whose name(s) could your veterinarian have listed as the owner(s) for your pets?
On average, how many hours a day will this pet be alone? (without human companionship)
Where will your dog be when no one is at home?

Indoors Outdoors Either indoors or outdoors
Where might your dog spend his day?

Loose indoors In crate Basement Garage Fenced yard Kennel Run Tied outdoors Other
If you selected 'other' to the above question please explain:
Where will your dog sleep?
Who will care for your dog when you are away from home over night?
When this animal is outside will it be...

In a fenced yard On a leash Allowed to run loose On a trolley chained other
If you selected "Other" to the above question, please explain.
If your new dog will be in a fenced yard, what type of fence do you have and how tall is it?
What circumstance(s) might justify giving up a dog? (Check all that apply.)

New Baby Divorce Dog not getting along with other pets Moving Allergies New household member dislikes dog Shedding Behavior problems House soiling/Urine marking Want to travel Dog becomes ill Destructive behaviors Children lost interest Too time consuming Other None
If you selected 'other' to the above question, please explain:
How much time do you plan to spend training your dog?
Are you willing to enroll your new dog into a training class?
Which of the following dog issues are you NOT willing to accept in your home?

Barking Separation Anxiety House Training Problems Digging Property Damage Chewing Jumping on People Shedding Mouthing Other I am willing to accept and work on all of these
If you selected 'other' to the above question, please explain:
When it comes to relating to dogs, I consider myself:

Strict, demanding, a strong leader (dog must obey commands and follow rules) Lenient, a little wishy washy, easily coerced by the dog (the dog looks cute, so he gets a treat without sitting and can jump on the couch univited) Somewhere in between
Are you experiencing any difficulties with your current pets in terms of health or behavior? If yes, please explain.
What do you know about heartworm disease and prevention?
On average, how much do you ESTIMATE it will cost you to care for your dog each year?
Do you understand that we MUST be contacted in the event that you can no longer keep the dog and agree to give us a reasonable time to find new placement for the dog?
Will you allow an ITV representative to see this animal in its new home?
REFERENCES - Please list three references that we may contact. One reference must be a Vet (if you have other pets). Other references may include family members, neighbors or co-workers that will know how to contact you in the future.
Full Name #1
First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone Number
- Area Code Phone Number
Relationship:
Full Name #2
First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone Number
- Area Code Phone Number
Relationship:
Full Name #3
First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone Number
- Area Code Phone Number
Relationship:
I certify that the above information is accurate, and that I have willingly provided it to It Takes a Village Canine Rescue, Inc. I will notify It Takes a Village Canine Rescue, Inc. of any changes related to this information. By signing below, I certify that the information I have given is true and that any misrepresentation of facts may result in my losing the privilege of adopting a companion animal form It Takes a Village Canine Rescue, Inc.
Adopter's Signature and Date:
ADOPTER'S AGREEMENT AND RELEASE

****Please read carefully and initial after each statement if you agree****
I agree that the animal is being adopted for myself and will not be sold, adopted or given to another party.
I agree that if at any point I decide that I cannot keep the animal for any reason, I will return him/her to ITV Rescue without requesting return of the adoption fee. In the event that I have to return the dog, I agree to give ITV reasonable notice and time to find alternative placement for the dog.
I understand that all dogs need a period of time to adjust to a new home, new people and a new evironment. I agree to allow an adopted dog a reasonable amount of time to adjust to my home.
I agree that the animal will not be allowed outdoors without proper supervision. When taking the animal outdoors, he/she will be on a secure harness and wear proper identification.
I agree to care for the animal in a humane manner and be a responsible animal guardian. This includes supplying adequate food, water, shelter, attention and medical care.
I understand that ITV Rescue has little or no knowledge of the animal, including its medical condition/background and disposition. ITV Rescue makes no warranties with regard to the health or temperament of the animal and disclaims any liability for the animal's medical condition, temperament, sickness or disease.
I give ITV Rescue permission to call or visit my home at any reasonable time to ensure that the animal is being properly treated and cared for.
When I assume ownership, the animal will receive annual vaccinations according to a veterinary schedule, and will be treated immediately for any illnesses or injuries that may occur.
The animal will not be subject to harassment by myself or other persons who live or visit my home, and will be protected from other animals in my care.
I release and forever discharge It Takes a Village Canine Rescue, Inc., its board, volunteers, foster homes and representatives, and veterinarians treating the animal at the request of It Takes a Village Canine Rescue, Inc., from any and all claims and actions, including, but not limited to property damage caused by the animal, personal injury to me, family members, third parties or other animals from biting, scratching, transmittal of disease, and/or any other matter attributable to said animal. I understand that any animal has the potential to bite or cause injury. I further agree to indemnify and hold harmless It Takes a Village Canine Rescue, and its board, volunteers, foster homes and representatives, veterinarians, joint and severally, from any and all actions, claims, and demands for, upon or by reason of any damage, loss or injury, which hereafter may be sustained by adoption of the animal.
I acknowledge that ITV Rescue is an Indiana non-profit organization and any disputes or disagreements arising from my dealings with ITV Rescue are subjected to Indiana law and I consent to the exclusive jurisdiction of Indiana law. I further consent to the exclusive jurisdiction of the Vanderburgh Superior Court to hear any disputes that may arise involving this agreement.
I understand and agree to the above terms. If, at any time, I am unable to care for the animal according to the conditions stated above, I will allow It Takes a Village Canine Rescue, Inc. to resume ownership of the animal or find an alternative solution. I understand that if I knowingly fail to comply with the above terms, or in any way put the animal in a situation which endangers its health, It Takes a Village Canine Rescue, Inc. may take appropriate action, including legal action to take the pet from my possession. I agree to pay ITV Rescue damages in the minimum amount of $300, plus attorney's fees, and/or allow for reposession of the dog for any breach of this adoption agreement.
Adopter's Signature and Date:
Should be Empty:

If you have any questions please email ITVrescue@gmail.com or call (812)250-WAGS

It Takes a Village Canine Rescue, Inc. reserves the right to refuse any applicant!

It Takes A Village Canine Rescue

Dog/Puppy Adoption Application