Adoption Application

Precious Paws Humane Society of Chisholm

101 SW First Avenue

Chisholm MN 55719

(218) 254-3300

To Adopt an Animal you must:Personal Information

  • Be at least 18 years oldName ______
  • Have consent of all adults living in householdAddress: ______
  • Have verifiable identification______
  • Have landlord’s consent—if rentingCity/St/Zip ______
  • Be familiar with your local animal ordinancesHome phone ______
  • Be able to afford itWork phone ______

Cell phone ______

*We recommend that you take your pet for a wellness checkDriver’s License # ______

within 1 week of adoption.Email ______

**After adoption, medical expenses are the responsibility of the adopter

HousingLifestyle/Family

Do you own or rent your home? ____ Own ____ RentIs animal for your household? ____ Yes ____ No

Please check type of home:Do you have children? ____Yes ____ No

____ Single Family Home ____ ApartmentAges of children in household?

____ Mobile Home ____ Duplex______

____ Townhome/Quad ____ CondoWhat is the maximum number of hours this

Do you plan on moving in the next 6 months? ____ Yes ____ Noanimal will be left alone?

Animal will be kept primarily? ____ In ____ Out

When outside, how will animal be confined? ____ FencedDoes anyone in your family have allergies?

____ Tie-out____ Yes ____ No

____ Kennel

____ OtherWhat other Animals do you currently have?

Explain if other ______Dog/Cat Length of time owned? Still have? ______

If renting, landlord’s phone #______

If renting, any restrictions? ______

Animal Desired? _____ Dog _____ CatAre all your animals spayed/neutered?__Yes __No Check reasons for adopting this animal: If not, why? ______

____ Companion _____ for Children _____ MouserWho is your Vet? ______

____ Gift _____ Hunting _____ Guard Dog

____ Other (explain) ______

Thank you for supporting Precious Paws

**Either a vet reference or a home visit is necessary before Humane Society of Chisholm and the thousandsapproving this adoption. of homeless animals.

Adopter’s Authorization

I certify that the information I have given is true and completePrecious Paws Humane Society ONLY

and I meet the adoption requirements as stated above:ID Tag #______

Animal’s Name:______

Signature:______Breed:______

Rep. Signature: ______

Date: ______Approved by:______Vet called:______

*We reserve the right to deny your applicationLandlord called:______

**Payment can be made by cash, check, or money order onlyReference Name and outcome:______

______

______

Adoption Center—Liability Form

Purpose of agreement: This form releases Precious Paws Humane Society of Chisolm (PPHSC) from all liability and risks posed in the act of an interested party meeting with an animal owned by PPHSC.

Release of Liability:

I agree to bring no action or claim against PPHSC or their officers or agents, by reason of this visit. If this is a “meet and greet” involving an animal I own, I understand I am responsible for my animal’s actions. I understand that PPHSC is not making any representations or warranties about any animal’s temperament or behavior. I acknowledge and agree that PPHSC is not responsible for any injury, damage, or harm caused by any animal and I hereby release PPHSC from any and all liability for any injury, damage, harm, expense or liability I incur. I also agree to indemnify PPHSC from any and all such claims and to pay, without limitation, any costs related to such injury, damage or liability, including, in the case of litigation, any attorney’s fees incurred by PPHSC in its defense.

Assumption of Risk:

I acknowledge that meeting with any animal can pose a risk to my safety and the safety of any minors accompanying me. Such dangers include, by way of example and not limitation, the risk that the animal can bite, trip, and knock down people, especially children, and can fight with other animals. I also understand that if an animal I own is taking place in a “meet and greet”, PPHSC is not liable for any injuries or damages that my animal sustains. Accordingly, the undersigned(s) assumes the risk of injuries, losses, damages, costs and expenses by of any sortdue to this visit. I understand and agree that PPHSC shall not be held responsible for the same.

I hereby declare that I have fully read and understand the terms of this release, and release PPHSC from all liability for myself, any animal I may own, and minors accompanying me.

The signatures below are those of any adults visiting PPHSC at this time.

______

Signature of Interested PartySignature of Interested Party

______

Printed Name of Interested PartyPrinted Name of Interested Party

______

DateDate

H:\DAA\Precious Paws Documents\Shelter forms\Adoption Application-revised 3-25-15.doc