Massena Humane Society
177 S. Racquette River Rd
Massena, NY 13662
315-764-1330
NAME_____________________________ PLACE OF EMPLOYMENT_____________________
ADDRESS__________________________ IF NOT EMPLOYED___________________________
(How will you afford vaccinations/vet care etc.?)
TOWN/ZIP_________________________
PHONE____________________________ Are you over 18? Yes No
TOWNSHIP________________________ Are there children in the house? Yes No
If yes what are their ages?_______________________
DO YOU: RENT ( ) OWN ( ) Does anyone in the house have allergies?___________
IF RENTING: Do you have permission Where will the animal live? Inside ( ) Outside ( )
from your landlord?_________________ Where will they sleep?___________________________
Landlords’ Name:___________________ Who will be responsible for this pet’s care?_________
Address:___________________________ ______________________________________________
Phone:_____________________________ Have you ever brought an animal into a shelter?
APT.________ HOUSE______________ Yes ( ) No ( )
What pets do you have now? Why were they surrendered?_____________________
Cats____________ Dogs_____________ ______________________________________________
Are they spayed/neutered?_____________
Are they up to date on vaccinations?_____ Have you had an animal die in the past three months from
Veterinarian’s Name__________________ Distemper, parvo or Leukemia?_____________________
PLEASE READ AND SIGN:
Massena Humane Society reserves the right to visit and inspect the premises where the pet is being kept. If the pet is not receiving adequate care we will remove the animal. It is expected that you will provide a LIFE LONG home for the animal, as well as proper nutrition and ALL necessary medical care. Our purpose is to place animals in loving, responsible homes where it will be treated as a family member. The Massena Humane Society reserves the right to refuse an adoption.
Most shelter animals have unknown backgrounds. This means the animal may be carrying an undetected illness or medical problem that did not manifest itself while the animal was in the care of the Humane Society. The Massena Humane Society relinquishes all responsibility of the above animal to the adopter. By signing below you are accepting possession and title of the animal as your pet and waive any right against the Massena Humane Society and/or Town of Massena in regards to the health and behavior of this animal. This animal now belongs to you.
NAME_______________________________________________ DATE________________________________
Witness_______________________________________________