Animal Friends of North Central West Virginia (AFNCWV)

Name: ________________________________________________________________________

Address: ______________________________________________________________________

City: ____________________________________ State: ___________ Zip: ______________

Phone: ___________________________________

Employer: _________________________________________     Work Phone Number:________________________

Email Address: ________________________________________________

Please complete all the information on the following pages. By signing below, you certify that you understand the following:

1. It is the AFNCWV organization's/representative's right to refuse adoption to anyone.

2. The information contained within this application is accurate and not misleading in any way.

3. It is AFNCWV organization's/representative's right to contact individuals on this form.

Date: ___________________ Signature: _________________________________________________________

Information on the animal of interest:

Name: ______________________________________________

Breed / Description: _______________________________

Sex: ________________________

Age: ________________________

1. Do you have other animals at home?   yes   /    no

If yes:

2. Have you had other animals as pets in the past?   yes   /    no

If yes then what happened to them?___________________________________________________________
___________________________________________________________________________________

And please list them below:

3.Who is/was your veterinarian? _____________________________________   How long? _____
    Name: _____________________________________    Phone:______________________
    Address: _______________________________    City: _____________________    State: _____

4. Where do you currently live?     house   / apartment   / other

5. Do you own or rent? (circle one).   If rent, does your lease allow pets?   yes /  no
    Landlord's name _____________________________________ Phone: __________________

6. How many people live in your household?   _______________     Do all the adults know you plan to adopt?    Yes / No
    If there are children in the household, list ages ________________________

7. Does anyone in your household have any known allergies to animals?    Yes  /  No

8. Where will this animal be kept during the day? ____________________________   At night? ________________________________

9. Is anyone home all day?     Yes / No If no, how many hours will the animal be left alone in a 24-hour period? _____________

10. Where will he/she be kept when alone? _____________________________________________

11. Are you financially prepared to give this animal routine and emergency medical care?     Yes / No

12. Would you object to a visit or call from us to see how you and your new family member are doing?     Yes / No

13. List two references (name, relationship, phone number)

    1) _______________________________________________________________________

    2) _______________________________________________________________________

14. Why do you want to adopt a dog? (circle/underline/highlight all that apply)
        companion for myself/family
        gift for someone else
        watch dog
        guard dog
        to breed
        companion for another animal

15. Do you realize you will probably have to housetrain the dog?   Yes / No

16. Are you familiar with crate training? Yes / No
   If yes, what is your experience with and/or thoughts about it?

17. Are you familiar with leash & licensing laws in your community? Yes / No

18. How will you be sure that your dog does not wander from your property? (circle all that apply)
       kept in the house
       kept in the garage
       kept on a chain/leash outside
       outside in a kennel
       we have a fenced-in yard

19. Do you have a fenced yard?   Yes / No    If yes, how high? ____________

20. What will you do if your dog chews furniture or shows other destructive behavior?

21. Are you familiar with the feeding recommendations for a dog/puppy?   Yes / No

22. Are you willing to take the dog to training classes?    Yes / No

I, ______________________________, adopt this animal and release the Animal Friends of North Central West Virginia organization from all claims for personal injury and/or property damage to myself or others associated with this adoption. The welfare of this animal will be my sole responsibility. I AM NOT ADOPTING THIS ANIMAL FOR ANOTHER PERSON. This animal will not be used for breeding, medical or experimental purposes. I understand that in the event I give false information or do not follow the terms of this contract, the adopter may remove this animal from my household without notice.

I HEREBY ACKNOWLEDGE RECEIPT OF THE ABOVE DESCRIBED ANIMAL AND THEREFORE AGREE TO THE FOLLOWING TERMS:

1. After adoption, this animal's health becomes my full responsibility. The adopter(s) will provide necessary veterinary care upon sickness, disease or injury. In addition, the adopter(s) will take this animal to a veterinarian at the adopter(s)' expense for yearly thorough exams and necessary shots. It is strongly recommended the exam include a stool sample test and heartworm test for dogs. Prevention from parasites is much cheaper, easier and safer than treatment.
   
   
2. THE DOG WILL NOT BE CHAINED TO A DOGHOUSE OR CHAINED OUTSIDE TO ANY TYPE OF OBJECT OR OUTBUILDING. THE DOG IS NOT TO LIVE IN A GARAGE, DOGHOUSE, OR ANY TYPE OF OUTBUILDING. SHELTER FROM WEATHER MUST BE PROVIDED FOR THE DOG AT ANYTIME THE DOG IS OUTSIDE.
   
   
3. The AFNCWV dog will not ride in the open bed of a pickup truck, under any circumstances such as in a cage/kennel, tied or loose. The dog shall not remain in any vehicle in extreme heat, with windows down, or unattended for any amount of time.
   
   
4. The dog is not to remain solely in a crate while indoors, only while the adopter(s) is not at home (if at all) and not for more than nine (9) hours a day. The crate must be large enough for the dog to stand up and turn around in, as well as having the proper floor space for the dog to lie comfortably on its side.
   
   
5. The adopter(s) will keep this animal in a private residence only. The adopter(s) has permission from the rental agency or property owner to have companion animals in their home. The dog is not to remain solely in one room while indoors, only while the adopter(s) is not at home is it to be confined to either the crate or a designated room. The dog will be permitted to roam the house and socialize as a family member when the family is home.
   
   
6. The adopter(s) will keep an ID tag on this dog at all times. When outside, the adopter(s) will keep this dog on a leash or in a fenced-in yard and not allow him/her to roam unattended. The dog will not wear a pinch (cleat) collar or any similar article around the neck for the purpose of any basic training, any basic correction, or for permanent use of identification. The pinch (cleat) collar is only to be used to correct a behavior problem, which is an isolated incident and only under the guidance of a professional dog trainer, and not to be used for any other reason.
   
   
7. The dog is not to be left unattended with small children at anytime.
   
   
8. The dog shall not be trained or encouraged to behave for the purpose of protection, aggression, attack, or any aggravated display or behavior.
   
   
9. The dog will be a family member only and only participate in good citizen, basic obedience, search and rescue, therapy dog training, or Seeing Eye dog training. The dog will not be maintained as property or for the purpose of being a deterrent due to size, appearance, or display and encouragement of territorial behavior.
   
   
10. The dog is to have adequate food, water and shelter at all times.
    
    
11. The adopter(s) shall refrain from physical abuse of the animal and from otherwise treating the animal in an inhumane manner.
    
    
12. If the adopter(s) can no longer keep this animal, the adopter(s) MUST telephone/contact the AFNCWV organization to arrange for re-adoption.
    
    The dog is never to be sold, leased, or given to any pet shop, animal shelter, research laboratory or similar facility. The adopter(s) will telephone/email/contact the AFNCWV organization immediately if this animal becomes lost.
    
    The adopter(s) will never abandon or give this animal to a shelter or another person. The adopter(s) will insure that this animal is never sold, given up for experimentation, or exchanged in any form. In the event the adopter(s) must give up this animal, the adopter(s) will abide by the terms of this contract and allow the AFNCWV organization sufficient time to arrange for re-adoption or foster care.
    
    
13. The adopter(s) agrees to receive telephone calls and/or visits from the AFNCWV organization representatives to check on the adjustment and progress of this animal.
    
    
14. The adopter(s) will telephone/email/contact the AFNCWV organization if the dog and family move and change address. We maintain a database of adoptions and should an illness develop in a sibling to the adopted dog, for example, AFNCWV will contact the adopters with this information as an alert to the dog's well being.

The adopter(s) agrees that if any of the above terms are not satisfactorily met, the AFNCWV organization has the right to reclaim this dog without notice.

Should it become necessary for the AFNCWV organization to take action to recover an adopted dog or otherwise enforce the provisions of the adoption contract agreement, the undersigned adopter(s) will be responsible for all court costs and all attorney fees representing either the adopter or the AFNCWV organization. Adopter(s) agrees to assent to the jurisdiction of the courts in the county and state where the AFNCWV organization deems to be the proper venue. This is a confidential agreement between the AFNCWV organization and the adopter(s). The AFNCWV organization shall not be held liable, charged, or chargeable for any misrepresentation unknown to this organization.

The AFNCWV organization makes no illicit or implicit guarantees in reference to the health and/or temperament of the dog. The dog is adopted "as is" and the adopter(s) assume all responsibility for treatment of any and all existing conditions or any other conditions of physical or temperament changes that may occur. The AFNCWV organization will provide the dog with basic vaccines and spay/neuter before adoption if the age and current health of the dog permits. While the AFNCWV organization makes every effort to place only healthy animals, they cannot guarantee the health of any animal and shall not be held responsible for any medical expenses which may be incurred, hereby expressly excluding any implied or express warranties of merchantability or fitness for any particular purpose, including, without imitation, any warranties regarding health, temperament or whether the animal is housebroken. The adopter(s) will not hold the AFNCWV responsible for errors in the information provided about this animal.

The adopter(s) understand that the donation made as part of this contract is a gift and not a payment for a value received. This donation is not refundable. This covers the spay/neuter operation of the animal that was recently performed and other expenses associated with fostering this animal. Amount of donation is $_______ made payable to the the Animal Friends of North Central West Virginia organization.
Note: the donation amount will be set to cover the costs of the veterinary care as agreed upon by the adopter and the AFNCWV organization plus the adoption fee.

The adopter(s) accepts all responsibility and liability for this animal at the date of adoption.

Date:__________________________________________

Adopter(s) Name:____________________________________________________

Adopter(s) Signature:____________________________________________________

The AFNCWV organization

Representative's Name:__________________________________________

Signature:______________________________________________________________

We can provide you additional information on the care and well-being of this pet. Just ask about any topic.
Some topics include but are not limited to:

• heartworm prevention,
• feline aids/leukemia,
• teeth cleaning,
• dew claw removal,
• dealing with behavioral issues.