<p> TOY POODLE RESCUE</p><p>You must be 21 years old and have a valid driver's license or picture ID to adopt a pet</p><p>Today's Date: </p><p>Name, number or description of Poodle you are interested in adopting or preference </p><p>1st choice</p><p>2nd choice </p><p>SECTION 1: PERSONAL INFORMATION</p><p>First Name: Last Name: Age:</p><p>Spouse/Partners Spouse/Partners Age: First Name: Last Name:</p><p>Address: </p><p>City: State: Zip: </p><p>Home Phone: Cell Phone: </p><p>E-mail Address: </p><p>I share my home with adults and children </p><p>Ages of children:</p><p>Ages of other children who visit?</p><p>Do you expect to add to your family in the future? </p><p>Does anyone else share or live in your home? </p><p>Occupation: Work phone:</p><p>Spouse Occupation: Work Phone:</p><p>Work Hours? Spouse/Partners Work Hours? Do all adults work full time? Yes No </p><p>Is anyone home during the day: Who?</p><p>How many hours each day will your new dog be alone, please include commute time:</p><p>Is everyone in your household in agreement on adopting a Toy Poodle:</p><p>SECTION 2: HOUSEHOLD INFORMATION</p><p>Residence: Own Rent Other</p><p>House Condo Apartment Mobile Home</p><p>What type of environment: City Suburban Country</p><p>If you rent, you must provide your landlord's contact information so that we may verify that you are allowed to have a dog.</p><p>Landlord’s Name: Landlord’s Phone: </p><p>Landlord’s Address: </p><p>How long have you lived at this address:</p><p>If under 5 years please list old address:</p><p>Does anyone in your house have any known allergies to dogs? Yes No </p><p>Does anyone in your household smoke? Yes No</p><p>SECTION 3: HISTORY</p><p>Have you owned a Poodle before? Yes No </p><p>Have you owned a dog before? Yes No</p><p>I currently own indoor cat (s), and in/outdoor cats </p><p>I currently own indoor dog(s), and in/outdoor dogs and these other pets: </p><p>Are the pets in your household spayed/neutered? Yes No Are the pets in your household current given vaccinations and see a vet annually? Yes No</p><p>Are the pets in your household current on heartworm medication? Yes No</p><p>Please list current pets in your home: Name M/F Breed/cross Color weight Age</p><p>Please list the pets you have owned over the last 10 years (not current) and what happened to them: Name M/F Breed/cross color weight Age Died </p><p>SECTION 4: DOG INFORMATION</p><p>Does your home have a yard? Yes No</p><p>Is there a fence that surrounds the property completely with no gaps or holes that a small Poodle could get out from? (fully fenced in yard)</p><p>Do you have an Electric fence Run Tie out </p><p>If you have no fence, how do you plan to have your new dog relieve itself and get exercise?</p><p>Where will your new Poodle be kept when it is alone as a puppy?</p><p>Where will your Poodle or existing pets be kept as adults when alone? </p><p>Where will your new poodle sleep at night? When you go away for a few days/vacation who will care for your Poodle?</p><p>What brand of food did you or do you feed your pets?</p><p>SECTION 5: REFERENCES</p><p>Please provide the contact information of a veterinarian you have used before and plan to use with your new dog. We do check vet references. Please call your vet and give permission to talk with us.</p><p>Vet Name: Vet Phone:</p><p>Office Name: Address:</p><p>City: State: Zip:</p><p>Vet records are under the owners name of: </p><p>Pets Name(s)</p><p>Groomers Name: Groomers Phone number:</p><p>Please provide at least three personal references. Include their name, telephone # and how this person knows you and your ability to provide a good home for a dog: No relatives please.</p><p>How did you hear about Toy Poodle Rescue?</p><p>I certify that the information I have given is true, and I understand that TOY POODLE RESCUE may contact my veterinarian, personal references and landlord to verify the information on this form. I also agree to a home visit from a representative of TOY POODLE RESCUE. I also agree that if the adoption doesn't work out for any reason, I will return the pet to TOY POODLE RESCUE ONLY.</p><p>Signature: Pets need veterinary care throughout their lives. Before deciding to adopt a pet, please be sure to you've budgeted not only for food, but also for annual vaccines and check ups, as well heartworm and flea/tick preventatives. Plus grooming fees can be $40-60 every six weeks. Please do not adopt a Poodle if you will not be able to provide it with ongoing care. TOY POODLE RESCUE VOLUNTARY RELEASE / WAIVER OF LIABILITY FOR ADOPTERS</p><p>This Voluntary Release/Waiver of Liability (the “Release”) is made and entered into between the undersigned and TOY POODLE RESCUE effective as of the below-indicated date. The undersigned desires to adopt an animal from TOY POODLE RESCUE, and hereby represents, acknowledges and agrees as follows:</p><p>1. I understand that TOY POODLE RESCUE cannot guarantee the health or temperament of the animals adopted from it. TOY POODLE RESCUE, its past, present and future officers, directors, agents and employees shall not be held responsible for any defects and/or illness which the animal may have or may develop and for any damage or injury to any person or property which may be caused by the animal. I hereby agree to release and indemnify and hold harmless TOY POODLE RESCUE, its past, present and future officers, directors, agents, and employees from and against any and all liability, claims, suits, actions, judgments, costs, fees, including attorney fees and damages for any damage or injury to any person or property which may be caused by the animal and/or arising out of and/or in connection with this animal. </p><p>2. I agree that I will not make any claims against, TOY POODLE RESCUE or attach any property of TOY POODLE RESCUE, its directors, officers, agents, employees and/or volunteers for any injury or damage caused by any animal(s) adopted from TOY POODLE RESCUE.</p><p>3. I hereby voluntarily release, discharge, waive and relinquish any and all actions or causes of action for personal injury, property damage or wrongful death occurring to me or third parties as a result of any action or activity of any animal(s) adopted by me from TOY POODLE RESCUE, wherever and however the same may occur which I may have against or any of its directors, officers, agents, employees or volunteers, whether the same shall arise by the negligence of said persons or otherwise. IT IS MY INTENTION BY THIS INSTRUMENT TO EXEMPT AND RELIEVE TOY POODLE RESCUE FROM ALL LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR OTHERWISE.</p><p>4. I HAVE CAREFULLY READ THE FOREGOING, AND I UNDERSTAND THAT TOGETHER THEY CONSTITUTE A DISCLAIMER OF LIABILITY BY TOY POODLE RESCUE AND A RELEASE OF ALL CLAIMS BY ME. I UNDERSTAND THAT I ASSUME ALL RISKS INHERENT IN MY DECISION TO ADOPT AN ANIMAL FROM TOY POODLE RESCUE AND ANY RELATED ACTIVITIES. I VOLUNTARILY SIGN BELOW TO EVIDENCE MY ACCEPTANCE OF THE ABOVE PROVISIONS.</p><p>5. If any portion of this Release is held invalid, it is agreed that the balance hereof shall continue in full legal force and effect.</p><p>6. This Release is governed by the laws of the State of Massachusetts applicable to agreements entered into and fully performed therein.</p><p>______</p><p>Print Name Signature of Pet Adopter Today’s Date</p>