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Adoption Application.
NOTE: Derby City Dog Rescue is located in Louisville, KY, USA. Out of area adoptions are considered.
Fields marked with * are required.
NOTE: AFTER YOU SUBMIT THE APPLICATION, YOU SHOULD SEE A CONFIRMATION MESSAGE. IF YOU DO NOT SEE THAT MESSAGE, PLEASE REVIEW YOUR APPLICATION FOR MISSING INFORMATION. IF YOU DO NOT SEE A CONFIRMATION MESSAGE, WE HAVE NOT RECEIVED YOUR APPLICATION.
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Indicates required field
Dog Applied For
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Applicant's Name
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Applicant's Email
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Co-Applicant's Name
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Last
Co-Applicant's Email
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Phone Number
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Best Time to Call
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Address
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Line 1
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City
State
Zip Code
Country
Do You Rent or Own Your Home?
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Rent
Own
If Rent, Provide Landlord Name
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Landlord Phone Number
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Names/Ages of All Persons in Household (including applicant)
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Do All Members of Household Agree With Adoption?
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Yes
No
N/A
Names/ages/descriptions of current pet(s) in home. Please indicate if vaccinated/spayed/neutered. (Type "N/A" if no current pets.)
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List last five pets (it is not necessary to list childhood pets). Please indicate if vaccinated or spayed/neutered? Why no longer owned? If deceased, give age and reason. (Type "N/A" if no previous pets.)
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Describe the physical environment in which the adopted dog will live (indoor/outdoor, where dog will sleep, crated and for how many hours per day, etc.)
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Please indicate whether yard is fully/partially fenced or if there is no fence. If fenced, give type (e.g., privacy, chainlink, farm, etc.) and height of fencing.
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What are your feelings about crating a pet?
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Would you object to periodic visits from a rescue representative?
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Yes
No
Do you agree to have annual checkups and all vaccinations administered by a veterinarian?
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Yes
No
Current or most recent veterinarian (clinic name, vet's name, address and phone). Type "N/A" if you have never owned a pet.
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Please describe what you ARE looking for in a dog and what you ARE NOT looking for in a dog.
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Why do you want a dog? (examples might be companionship, protection, hunting, dog sports--include any reasons that apply)
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If you move in the future, what will you do with the pet?
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If adopting this pet for someone else, please explain.
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Please list three personal references. (References cannot live in applicant's household.)
Reference Name
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First
Last
Phone Number
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Reference Name
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First
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Phone Number
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Reference Name
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First
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Phone Number
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Please read the following before submission of application. If approved for adoption, the following constitutes your contract with Derby City Dog Rescue.
By submitting this application, I understand that, if approved, I agree to the following terms and conditions:
* I understand that there will always be an adjustment period for any dog coming into my home. The average is 3 weeks to 3 months, and I am willing to work with this pet to assist it in becoming a member of the family, including gradually introducing it to our home and family (including other animals), through the use of a crate, and monitoring the dog’s exposure to these things as needed. I also understand that many of these dogs have survived incredible odds and need lots of extra care and patience.
* I agree to provide proper and sufficient food, water, vet care, and humane protection as the animal may require throughout its lifetime at my expense. If the dog becomes seriously ill or injured, I will still care for the animal and assume the cost of veterinary care.
* I understand that all dogs adopted from Derby City Dog Rescue are adopted as family members that reside indoors with their owners. Derby City Dog Rescue adopts canine companions and does not guarantee that any dog is a working dog. Many will work naturally, but it is not guaranteed.
* I agree that an ID tag with my phone number and current license, attached to a properly fitted and buckled collar, will remain on the dog at all times.
* I agree to train this dog using firm but fair methods only. I will not abuse the dog by hitting, kicking, starving, shocking, whipping, etc. (Note: Hitting a dog repeatedly on the head, can cause epilepsy). I understand that most rescue dogs have already experienced these abusive methods and that part of Derby City Dog Rescue’s mission is to save these dogs from abusive owners and adopt them to new owners who do not abuse them. The expectation is that the animal will have a better life than it did previously.
* I AGREE TO ASSUME ALL LEGAL RISK AND OBLIGATIONS OF OWNERSHIP. Further, I agree to waive all claims against Derby City Dog Rescue or its agents, servants, or members for illness, injury or property damage arising out of or in any way related to the adoption of a dog and to indemnify Derby City Dog Rescue for any and all such damages incurred.
* I agree not to surrender this live animal to be used for the purposes of vivisection or experimentation. I further agree not to surrender or rehome this animal to any shelter, rescue, or individual without written permission in the form of a new contract with Derby City Dog Rescue.
* I agree to notify Derby City Dog Rescue if, for any reason, I am unable or unwilling to keep this animal. I understand that Derby City Dog Rescue will accept any animal adopted from them back into their care.
* I agree to notify Derby City Dog Rescue if the animal is lost or believed stolen and to retrieve the animal from any animal shelter if impounded.
* I agree that under no circumstances will this dog be allowed to ride in the back of an open truck or in a car with the window(s) wide open. If needed, there are harnesses designed for a dog to safely ride in a vehicle.
* I agree that I will not have this animal euthanized unless it is necessary for the humane relief of suffering due to serious and untreatable illness, injury, or other condition, and will only do so with the advice of a qualified veterinarian.
* I agree to allow a designated agent or member of Derby City Dog Rescue to visit me at my premises, with prior notice, to check on the welfare of the adopted dog. I also agree to allow said agent or member to remove my adopted dog after any such inspection, if the agent or member is not reasonably satisfied that said dog is being properly cared for or the agent or member reasonably believes the animal is being abused or the adopter/residence is in any way unsuitable. Should I disagree with the agent or member's judgment, I agree not to sue Derby City Dog Rescue, but will submit the dispute to arbitration with a neutral arbitrator experienced in animal care and agreed upon by both parties. Each party is to bear its own costs and attorney's fees for such arbitration.
* I agree that Derby City Dog Rescue reserves the right to reclaim both possession and ownership without payment of any kind with or without court action in the event that I do not comply with the adoption contract provisions. In the event that Derby City Dog Rescue reclaims the pet I will waive claims that I might otherwise have arising from such reclaiming.
* I understand that if the dog dies as a result of breaking any of these covenants, my relationship with Derby City Dog Rescue will be terminated. Derby City Dog Rescue will not "find me another dog" to adopt nor recommend me to another group or shelter. I further understand that under certain circumstances (e.g., neglect, abuse, or rehoming/surrendering without permission) that Derby City Dog Rescue may inform other rescue groups and shelters of the situation in an effort to protect other animals.
* I also agree that if the information given pertaining to this adoption is found to not be accurate to the best of my knowledge, I forfeit all rights
and ownership of the dog adopted from Derby City Dog Rescue.
* I further agree to pay and reimburse forthwith Derby City Dog Rescue for any and all legal fees and court costs it incurs in enforcing the terms and conditions of this contract.
RETURN POLICY/TRIAL PERIOD
I understand that I, the adopter, must return the dog to Derby City Dog Rescue if the adoption is unsuitable. Unsuitable is defined as a problem which cannot be resolved with either a family member or other animal within the family. The adopted dog is to be returned to Derby City Dog Rescue, not sold or given away. I further understand that the adoption fee money has already been spent toward saving the life of the next homeless dog and, therefore, I will not receive a refund of the adoption fee. I understand that I should maintain diligent contact with Derby City Dog Rescue through the important and crucial first two weeks that the dog is in my home and alert them of any problems I may have with my new dog. If no contact is made, Derby City Dog Rescue will assume there are no problems. Derby City Dog Rescue will make an attempt to check on the dog within that time period, as well.
If life circumstances change and I cannot keep the animal, I will contact Derby City Dog Rescue FIRST and make arrangements to return the animal. I understand that Derby City Dog Rescue may require me to hold the dog until space can be made available for it within their foster home network. A health certificate is required prior to return. I will not sell or give the dog away to anyone without prior written approval from a Derby City Dog Rescue agent. I will be responsible for the cost to return this pet.
HEALTH/TEMPERAMENT
I understand that all dogs are adopted “AS IS.” Most animals adopted through Derby City Dog Rescue have been rescued from shelters and, therefore, there is often little or NO known history on any individual animal. All estimates of age and assessment of temperament are based, first, on shelter evaluations and further validated by the foster home(s) in which they reside while in rescue. Derby City Dog Rescue makes every effort to place only healthy animals of suitable temperament, but cannot guarantee the "future" health or temperament of any adopted animal. As an adopter, I am responsible for making the “hard choices” that any owner would have to make should the animal become gravely ill or become overtly aggressive.
I understand that all medical records for the dog I am adopting will be provided to me within a reasonable time period after the adoption is finalized. I understand that a health check by my veterinarian should be done within one week of taking possession of said dog. I acknowledge that Derby City Dog rescue would never knowingly adopt a dog with undisclosed physical or temperamental problems. I will ensure that my veterinarian knows the "normal" temperament of this dog’s breed. If there is an unforeseen problem, I will contact Derby City Dog Rescue immediately.
HEARTWORM WARNING: It has been discovered that a dog can test negative for Heartworm but later test positive, even if preventative has been
given in the interim. This is because at the time of initial testing the adult female heartworm had not developed enough to produce antigens that would show up when the first test was taken. It is not Derby City Dog Rescue’s responsibility or fault if the dog tests positive for Heartworm at a later date. By signing this adoption contract I release Derby City Dog Rescue from all financial liability stemming from a positive Heartworm test after adoption. Derby City Dog Rescue has taken every precaution to ensure any dog adopted is free of Heartworm infection. It is very important to keep my dog on a Heartworm Preventative program during the mosquito season, so he/she does not get Heartworms. (Note: Puppies under six months cannot be tested for existing Heartworm infection.)
Upon adoption a written copy of this contract must be signed.
I have read and agree with the above terms and conditions
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Yes
No
Electronic Signature
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First
Last
Date
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You must click the "Submit Application" button below to send your application to Derby City Dog Rescue. If, after clicking, you do not see a message confirming your submission, please re-check your form for missing information.
Submit Application
