Address: 

City:    State:    Zip: 

Your email address: 

Home Phone:    Work Phone: 

Which pet are you interested in? 

Where would your pet stay? 

Do you have a fenced yard?Yes No     If Yes, How high? 

Do you have any other pets?Yes No

If yes, describe them:

Are their shots current?Yes No       Date of Expiration:      

  Are they on heartworm prevention? Yes No   

Are they spayed/neutered?Yes No   

If not, why not?

Veterinarian:      Name:

                                Phone:     May we contact him/her? Yes  No

Do you understand the history of the animal you are adopting?  Yes  No     

Do you have children?Yes No     If so, what are their ages? 

Do your children understand the responsibilities of caring for animals?  Yes  No

How much time will this pet spend alone? 

May we visit your home?Yes No

Briefly describe your past experiences with pets:

How much time are you (and your family) prepared to spend with the adopted animal?  Are you willing to spend time socializing and training the adopted animal?  Please describe:

In case you experience a life change (for example, a move, a divorce, a new baby), how will this affect the adopted animal?

Do you understand that adopting a pet is a commitment for the animal's entire lifetime?  Are you willing to accept that responsibility?  Yes  No

Personal reference(s):  Name:   Phone:

                                   Name:   Phone:

Terms of Adoption

	If, at the time of the adoption, my adopted pet was too young to be spayed/neutered, I agree to take my pet to a Stay Rescue of St. Louis veterinarian within 3 months of the adoption to be spayed or neutered at no cost to me.
	If, for any reason or at any time, I am unable to care for my adopted pet, I agree to return my adopted pet to Stray Rescue of St. Louis; I further agree never to abandon my adopted pet or deposit my adopted pet at an animal shelter or research facility; however, before returning my adopted pet to Stray Rescue, I agree to exhaust all options available to me including, but not limited to, obedience training, a behaviorist, crate training or veterinary advice to solve any physical or behavioral problem that may occur with my adopted pet or between me and my adopted pet.
	I agree that by accepting my pet for adoption, I am accepting ownership of the animal.  I understand this means that Stray Rescue of St. Louis is not responsible for any damage to person or property that may be caused by my adopted pet after the date of the adoption and I accept full responsibility for my adopted pet from the date of the adoption forward.

Do you agree to the above terms?  Yes  No

I represent that the information that I have provided on this form is the truth to the best of my knowledge and belief.

By:   Date:

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