Intake Application

 

 

This form will not submit unless all fields are answered. Please put "N/A" if the question does not apply to you.

 
Working Email Address for Response
Your Email Address:
Applicant
Co-Applicant
Full Name: Full Name:
Age: Age:
Street Address: Street Address:
Town/City: Town/City:
State: State:
Zip Code: Zip Code:
Home Phone: Home Phone:
Cell Phone: Cell Phone:
Place of Employment: Place of Employment:
Nature of Employment: Nature of Employment:
Work Phone Number: Work Phone Number:
Tell Us About Yourself
How did you hear about us?
If  "other" please explain:
   
Which one of the following is this animal?
Cat Dog
 
Did we adopt this animal to you?
Yes No
 
What is the age of the animal?
 
What is the breed?
 
How long has the animal been in your care?
 
What is your reason for wanting to relinquish this animal to the care of The Dog House Rescue?
Are you willing to foster this animal in your home until we place it?
Yes No  
 
Do you have the medical history for this animal?
Yes No  
 

 

No cost is spared for the Feeding, Boarding, and Medical needs of any animal accepted into the program. Are you aware we have a $35 minimum fee (per animal) for animal relinquishments and willing to pay that fee upon relinquishment of the animal in question?

Yes No

 
What method of payment do you prefer?
 
How did the animal come into your care?
 
Are you aware of any sickness/Illness that this animal may have or be in the process of showing signs of? Yes No
 
Is there any reason you feel this animal may not be adoptable or easily placed in a loving home once/if we accept it? Yes No
 
If so please explain why?
 
Please list any Foster or Rescue programs you are a part of:
 
 
Please list the names and phone number of two personal references:
Reference1
Reference2
 
Please read the legal section carefully and enter your name below.

For and in consideration of The Dog House Rescue and Adoption, Inc. (the "Dog House Rescue and Adoption") allowing you to adopt one of it's animals, the receipt and sufficiency of which is hereby acknowledged, you agree as follows:


In signing this adoption agreement, you agree and acknowledge that you have fully informed The Dog House Rescue and Adoption about any history, medical problems or treatments, and/or behavioral problems or issues associated with the animal you are relinquishing to us. Upon full disclosure of this information, you hereby exempt The Dog House Rescue and Adoption, Inc. and it's staff or representatives from all legal damages which may be associated with such information.


You understand that if this application contains any false or misleading information, The Dog House Rescue and Adoption, Inc. reserve the right to deny any intake application for any reason.
By entering your name below you are entering into a binding agreement between yourself and The Dog House Rescue & Adoption Inc. and are in agreement that all information on this form has been filled out correctly and honestly to the best of your knowledge.

 

 
I have read the legal section and agree to its terms. Yes , I agree No, I do not
   
Name(required) and Driver's License(optional on form only)
Name
Date
Driver's License#