Safe Haven of Iowa County

P.O. Box 444

Williamsburg, Iowa 52361

319-622-PETS(7387)

WELCOME TO THE SAFE HAVEN OF IOWA COUNTY APPLICATION FORM FOR ANIMAL ADOPTION

Safe Haven of Iowa County has assumed responsibility for the welfare of every animal that enters our care. Our purpose is to place an animal in a responsible home for the rest of its life. This must be a home where it will receive veterinary care when needed, and where it will be controlled so as not to become a free roaming animal, or add to the surplus of animals already in the community.

The animal you are adopting has been surrendered, abandoned, or in some way displaced. It may have been abused or neglected. There may be only limited, if any, information available regarding the animal’s previous environment.

To ensure these ends, we have formulated this application form to assist our staff in the careful selection of home placements for our companion animals available for adoption. Only those persons who are adults of legal age will be eligible to adopt from our shelter.

WE RESERVE THE RIGHT TO REFUSE ANY ADOPTION

Name ______Date ______

Street (not PO Box) ______City ______State______

Zip ______Home Ph ______Work Ph ______Cell Ph ______

E-mail address: ______

Which animal are you interested in: ______

How long have you lived at your current address?:______

Are you 18 years of age or older?: ______

In what type of home do you live: ______

Do you own or rent your home: ______

If you rent, have you received the approval of your landlord to have an animal: ______

If you rent, please enter your landlord's name and phone number: ______

Have you, or any other member of your household, ever been arrested, charged or convicted of any animal-related crime such as failure to provide adequate care, animal cruelty, animal abandonment, animal neglect or any crime of moral turpitude: ______

Are you willing to allow a representative of Safe Haven of Iowa County to complete random home inspections throughout the pet's stay:______

Have you ever adopted from Safe Haven of Iowa County before: ______

If your response to the previous question was "YES", please tell us when you adopted or applied to adopt from Safe Haven of Iowa County: ______

Have you applied with any other rescue:______

How many people reside in your household and in particular, how many children reside with you and what are their ages: ______

Who in the household will care for the pet: ______

Why are you interested in adopting a pet at this time: ______

Do you currently have any pets? If so, please list how many and what kinds of pets you currently own (Cat, Dog, Reptile, Barnyard): ______

What kinds of pets (if any) have you owned in the past five years: ______

Do you currently have a Veterinarian for the pet you own (if any): ______

Veterinarian's Name and address: ______

What is your Veterinarian's telephone number: ______

May we contact your family Veterinarian for a reference: ______

If you currently own a pet(s), are your pet(s) shots up-to-date?: ______

When was your pet(s) last seen by a Veterinarian: ______

What was the reason for your pet(s) last visit to the Veterinarian?: ______

If you move to a new home, what will you do with your pet(s)?: ______

Are you aware that in the first year alone, Veterinary care for an adult dog or cat can cost upwards of $150.00 and care for a kitten or puppy can cost upwards of $200.00? : ______

Are you aware that in the first year alone, pet food, pet supplies and obedience training can cost upwards of $150.00 for a dog and $100.00 for a cat?: ______

Are you aware that a dog can live more than 15 years and a cat can live for more than 20 years?: ______

Do you, any member of your household or anyone who visits regularly have any pet allergies?: ______

If your response to the previous question was "YES", please tell us who among your household or regular visitors has allergies and to which animals?:______

Is your yard fenced: ______

What type of fence: ______

What is the height of the fence: ______

List two references, including phone numbers, of people who are not family members and not your vet: ______

______

List one reference that is a family member including their phone number:______

How much time will the animal spend alone during the day: ______

Where will the animal be kept when you are home: ______

Where will the animal be kept when you are not home: ______

Where will the animal sleep:______

Will the animal be kept inside or outside: ______

Describe how you will train the pet: ______

Please describe the area in which the animal(s) you might adopt will be kept.:______

If you currently have pets, are they spayed or neutered?: ______

What will you do if your pet urinates in your house (dog) or outside the litter pan (cat)?: ______

What will you do if your animal keeps you awake at night?: ______

What will you do if your animal becomes sick or suffers an injury?: ______

What type of identification do you plan to place on your animal?: ______

Do you feel that domestic female animals should be spayed?: ______

Do you feel that domestic male animals should be neutered?: ______

Do you understand that pet overpopulation is a serious problem?: ______

It may take your new pet two weeks or more (perhaps longer if other animals are involved) to adjust to its new home, are you prepared to allow your new pet time to adjust to its new surroundings?: ______

What will you do to help your new pet adjust to its new home?: ______

How did you hear about us: ______

I certify that the information I have given on this adoption application is true and correct and that I recognize that any misrepresentation of the facts submitted herein may result in losing the privilege of adopting or keeping an adopted animal. I understand that Safe Haven of Iowa County has the right to deny my request to adopt an animal, and I authorize investigation of all statements in this application. I understand that this application is the property of Safe Haven of Iowa County.:

I certify that the information entered on this applicant is true.

Signature______Date______

Disclosure and Release Clause
I,______, the undersigned, do hereby declare that I am aware:

  1. that animals are different from human beings in their response to human actions;
  2. that the actions of animals are often unpredictable;
  3. that animals should be closely supervised when they are with children;
  4. that an animal's behavior may change after it leaves the shelter and accustoms itself to a home or other different environment;
  5. that Safe Haven of Iowa County makes no claims or representations as to the temperament, health or mental disposition of any animal put up for adoption
  6. that Safe Haven is not held liable for conditions arising from the adoption of an animal. THE ADOPTING FAMILY DOES HEREBY RELEASE, DISCHARGE AND HOLD HARMLESS SAFE HAVEN of IOWA COUNTY AND ANY PERSON, FIRM OR CORPORATION CHARGED OR CHARGEABLE WITH LIABILITY TOGETHER WITH THEIR HEIRS, ADMINISTRATORS, EXECUTORS, SUCCESSORS AND ASSIGNS FROM ANY AND ALL CLAIMS, DAMAGES, COSTS, EXPENSES, LOSS OF SERVICES, ACTIONS OR CAUSES OF ACTION, WHETHER KNOWN OR UNKNOWN, BELONGING TO THE FAMILY DUE TO ANY ACTION OR OCCURRENCE ARISING OUT OF OR IN CONNECTION WITH THE ADOPTION OF A PET FROM SAFE HAVEN.
  7. This animal will be cared for and treated with love and respect. I agree to assume full responsibility for its well-being, including providing adequate and wholesome food, fresh water, shelter from the weather and any veterinary treatment needed to provide continued health and well-being of the animal.
  8. Dogs will not be kept on a chain because of the health hazards that may occur, the lack of exercise chains prevent and the potential dangers it may cause such as teasing and being trapped with no escape.
  9. Dogs will not be solely used as hunting or guard dogs. Cats will not be used solely as barn cats or mousers.
  10. I agree to abide by all city and county animal control ordinances, specifically any leash laws to prevent the animal from roaming and becoming a nuisance animal.
  11. It is expressly understood that such animal is NOT to be sold, traded, or given away for any purpose. It is not to be abandoned. It is not to be used for experimentation, resold to a lab or treated in any other inhumane way.If I cannot provide for the animal any longer, I will return it to Safe Haven of Iowa County.
  12. Adopter agrees that, without liability, Safe Haven of Iowa County may investigate the adopter’s home and the conditions under which the animal is being kept, and may take possession of the animal, if in the opinion of Safe Have of Iowa County, it is receiving less than adequate care, is being improperly housed or handled, or if any other condition of this contract is being or has been violated. In the event the adopter fails or refuses to return such an animal upon demand, the adopter hereby agrees to pay reasonable attorney’s fees in the event an attorney is consulted or if suit is brought for the return of the animal. The adopter acknowledges reading and understanding all policies within this contract and accepts this animal as a pet and companion, and willfully accepts the terms outlines within this legally binding agreement.

I agree to all the above statements and understand my responsibilities to the fullest extent.

SIHC Representative______Date______

Adopter______Date______