<p> Adopter’s Information for Homeward Bound Dog Rescue</p><p>Name(s) (last, first, middle; information for both if couple is adopting):</p><p>Mailing Address:</p><p>Street Address:</p><p>City, State, Zip:</p><p>Birthday, Driver’s License (or other gov’t. issued i.d.) #, State of Issue, and Expiration Date:</p><p>Home Phone:</p><p>Mobile Phone:</p><p>Current Employer, Address, & How Long; Previous Employer, Address, & How Long:</p><p>Work Phone:</p><p>E-Mail:</p><p>Preferred Method of Contact (circle or highlight): Home Phone Mobile Phone Work Phone E- Mail</p><p>Names & ages of others residing at same address (indicate relationship(s) and if anyone is allergic to animals):</p><p>Description of animals currently residing at same address (name, species, breed, sex, age, altered or intact, how long animal has lived with you, heartworm preventative used):</p><p>Description of animals you’ve previously owned (name, species, breed, sex, age, altered or intact, how long animal lived with you) and explain why they no longer live with you and where they are now:</p><p>Reason for adopting a rescued canine in general and this rescued canine in particular:</p><p>Living Arrangements (circle or highlight): Apartment Condo House, Owned House, Rented Landlord’s Contact info (name, phone #) if applicable (Landlord will be contacted prior to placement to ensure permission is granted to house adopted canine on premises):</p><p>I certify I have researched the applicable regulations / ordinances which apply to me and I am not restricted from having this breed, mix of this breed, and / or this type of dog by them (homeowners’ associations’ regulations, renter’s or homeowner’s insurance policies, local government ordinances, etc.): _____ Yes (initial here)</p><p>Dog walking area info (circle or highlight one and provide description): </p><p>Fenced private area (describe fencing material, fence height, and approximate size of fenced area) </p><p>Fenced public area (describe fencing material, fence height, and approximate size of fenced area)</p><p>Other (describe)</p><p>Primary Veterinary Reference (name, address, phone #, how long used):</p><p>Secondary Veterinary Reference (name, address, phone #) (Emergency vet if primary isn’t available):</p><p>Personal Reference #1 (name, address, phone #, description of relationship – must have known you in context of animal care for at least 2 years and cannot be living with you or be your relative):</p><p>Personal Reference #2 (name, address, phone #, description of relationship – must have known you in context of animal care for at least 2 years and cannot be living with you or be your relative):</p><p>Person who will be primarily responsible for my adopted dog’s feeding, walking, exercising, housetraining, etc.:</p><p>Person who will take care of my adopted dog during planned absences (vacations, business trips, etc.; name, address, phone #, description of relationship):</p><p>Emergency contact person who will be temporarily responsible for adopted dog if I cannot care for it for any reason (name, address, phone #, description of relationship): My adopted dog will be sleeping here:</p><p>My adopted dog will be alone during the day for no more than (list amount of time):</p><p>My adopted dog will be here when unsupervised:</p><p>In the event of a move, divorce, financial hardship, or incapacitating illness and / or death of me and / or my partner if applicable, my adopted dog will (indicate care arrangements):</p><p>I am prepared to commit (insert amount) $______for initial care (to include adoption fee and initial vet visit and initial purchase of housing, bedding, toys, equipment, etc.) and (insert amount) $______for annual care (to include annual vaccination and licensing requirements, veterinary checkup, food, supplies, etc.) of my adopted dog. I understand and agree that this section is solely to give Homeward Bound Dog Rescue and / or its designated representative(s) an indication of my understanding of and the ability to commit to the resources necessary to properly care for my adopted dog. I understand and agree that it is impossible to predict the exact expenses necessary to properly care for any given animal. I agree that I will care for my adopted dog to the best of my ability within my resources and will seek assistance from Homeward Bound Dog Rescue and / or its designated representative(s) if I am no longer able to provide for it adequately according to the terms of this contract. I agree to surrender my adopted dog back to Homeward Bound Dog Rescue and / or its designated representative(s) if required under the terms of this contract.</p><p>Homeward Bound Dog Rescue call name of rescued canine being adopted:</p><p>Sex and whether or not spayed or neutered of rescued canine being adopted:</p><p>Approximate age of rescued canine being adopted:</p><p>Physical description of rescued canine being adopted (predominant breed if applicable, appearance, size, any distinguishing markings, etc.):</p><p>Microchip # and / or rabies and / or license #s of rescued canine being adopted:</p><p>Activity level of canine being adopted: Active Quiet Moderately Active Unknown</p><p>Special Behavioral Characteristics of canine being adopted (circle or highlight):</p><p>Barker Whiner Climber Jumper Chewer Shredder Digger Separation Anxiety </p><p>No special behavioral characteristics noted</p><p>Special Medical Needs of canine being adopted (circle or highlight):</p><p>Special Diet Incontinent Thyroid problems Arthritic Seizures Demodectic Mange </p><p>Incapacitated due to Previous Injury (describe) Complications from Previous Illness (describe)</p><p>No special medical needs noted</p><p>I agree that I will take my adopted dog to my veterinarian for a physical as soon as practical, and not later than when my adopted dog’s next heartworm treatment is due (insert date) ______. Additional veterinary care to be provided by adopter’s veterinarian upon placement (specify):</p><p>I understand my veterinarian may be contacted to verify this care has been provided. I agree to the following adoption fee as set by Homeward Bound Dog Rescue and / or its designated representative(s) (insert amount): ______, and understand that this fee is NOT tax- deductible. I agree to provide this amount to Homeward Bound Dog Rescue and / or its designated representative(s) via cash, certified check, or money order made payable per Homeward Bound Dog Rescue and / or its designated representative(s)’s request and agree this contract serves as my receipt for this adoption fee. I understand this adoption fee is non-refundable once I have taken possession of my adopted dog unless other arrangements have been made herein or in writing in advance and agreed to by all parties.</p><p>CERTIFICATION: I certify all the above information is true and correct to the best of my knowledge and understand it is subject to independent verification. I understand and agree that I may be required to surrender my adopted dog back to Homeward Bound Dog Rescue and / or its designated representative(s) under the terms of this contract. I agree that failure to voluntarily surrender my adopted dog under such terms will be grounds for Homeward Bound Dog Rescue and / or its designated representative(s) to take legal action to recover my adopted dog and that I will be responsible for any and all expenses, legal and otherwise, necessary for Homeward Bound Dog Rescue and / or its designated representative(s) to affect the recovery of my adopted dog under the terms of this contract.</p><p>______Adopter’s Signature & Date Name (Print): ______</p><p>______Partner’s Signature & Date (if applicable) Name (Print): ______</p><p>______Canine’s Foster Parent Signature & Date (if applicable) Name (Print): ______</p><p>Homeward Bound Dog Rescue & Friends Adoptions c / o Jo Ellen Cockroft 14356 Retablo Helotes, TX 78023 e-mail: [email protected] ______Rescue Organization’s Representative’s Signature & Date Name (Print): ______Title (Print): ______</p>