First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Employer:*

Spouse/Partner's Employer:

Are you a Student?*
Choose one: Yes No

HOUSING INFO:

In what type of home do you live*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Farm

Do you own or rent your home*
Choose one: Rent Own

If rent, enter landlord's name and phone:

MCHS does not adopt cats into Non-Permanent Housing arrangements, such as Dorms, Group Homes, Nursing Homes, Assisted Living, etc.

HOUSEHOLD INFO:

How many adults in your home?*

How many Children?*

Children's Ages?

CURRENT AND PAST PET INFO:

Which animal are you interested in?
Choose an animal: Abby Ackston Adeline Alan Alex Alma (aka Pretty) Andrea Angelo Apollo Aries Art Athena Ava Baby Bagheera Barkley Beckham Belle Benny Beth Billy Blu (long term resident) Bronco Buster Charlie Chester Chip Christian Clarissa Claudia Dani (longterm resident) Dayle Deli Dexter Dona Ed Emerald Faith Finny Fizz Flynn Forest (Sponsored Fee) Frank Franklin Frieda Gabe Gabriel GARY Gary Glenn Goldie Greta Grey Hayden Hickory Hudson Ingrid James Jasmine Javvy Jewel Jim JT Karina Karlie Kate Katrina Kias Kindra Kipper Kirby Lainey Lance Leah Lexus Lizzy (adoption pending) Lucinda Lucky Lucky (Sponsored Fee) Lucy Ludwig Lynn Mango Max Maxine Mia Michonne Middy Milo Mittens Moe Moxie Muffin Mya Myla Nellie Nelson Noel Noodle Nova Oakley OLI PATTY PIPER Podge Quill QUINT Randi Reuben Rhonda Riggs Roberta Rocky Rome Romeo Rosita Rowen (Sponsored Fee/longterm resident) Rudy Sabrina Sebastian Shadow Shontell Simba Smokey Sonya Story Superman Tami Teddy Theresa TIMMY Toby Keith Todd Velvet Vicki Wild Bill Wilson Yolanda

Do you currently own other animals?

How many Dogs? And please provide Name(s)

How many Cats? And please provide Name(s)

Name of your Regular Vet Clinic?*

Vet Phone Number & Contact Name?

If you do not have an animal now, have you had one in the past?

Dog (breed)

Cats

How Long?

What happened to this pet?

I understand and accept that MCHS cats are adopted as INDOOR ONLY cats.*
Choose one: Yes No

I understand and agree that if this cat goes outside it MUST BE leashed or confined to my property.*
Choose one: Yes No

You understand and agree that this adoption is subject to your agreement to take proper care of the animal, and that your ownership is revocable by the Mower County Humane Society (“MCHS”), If it determines, in its sole discretion, that you are in breach of this contract. You agree that a MCHS representative has the right to visit your home at any time after this adoption to assess the conditions and adherence to this contract. The animal must have food, water, correct shelter and proper care. If the MCHS believes, in its sole discretion, that the animal is not being properly cared for in any way, or you are otherwise in breach of the terms of this contract, the MCHS retains the right to remove the animal from your home at any time and without notice.   Adopter understands that the animal will be returned to MCHS if the adoption does not work. The animal will not be privately re-homed.

It is understood and agreed that the MCHS is a non-profit all volunteer organization that provides a service of placing animals in homes and that the Non-refundable fee you are charged is a nominal amount which is intended to partially offset the costs the MCHS has incurred. Although the MCHS makes every effort to ensure the health of the animals, it makes no warranty or representation regarding the condition or health of any animal. You agree to indemnify, defend and hold the MCHS, its officers and volunteers, harmless from and against any losses, injuries, claims, or damages arising in any way from the adoption of any animal from the MCHS.

I UNDERSTAND AND AGREE WITH THE ABOVE:

---------------------------------------------------- MCHS USE ONLY-------------------------------------------------------

NAME OF ANIMAL:
Choose an animal: Abby Ackston Adeline Alan Alex Alma (aka Pretty) Andrea Angelo Apollo Aries Art Athena Ava Baby Bagheera Barkley Beckham Belle Benny Beth Billy Blu (long term resident) Bronco Buster Charlie Chester Chip Christian Clarissa Claudia Dani (longterm resident) Dayle Deli Dexter Dona Ed Emerald Faith Finny Fizz Flynn Forest (Sponsored Fee) Frank Franklin Frieda Gabe Gabriel GARY Gary Glenn Goldie Greta Grey Hayden Hickory Hudson Ingrid James Jasmine Javvy Jewel Jim JT Karina Karlie Kate Katrina Kias Kindra Kipper Kirby Lainey Lance Leah Lexus Lizzy (adoption pending) Lucinda Lucky Lucky (Sponsored Fee) Lucy Ludwig Lynn Mango Max Maxine Mia Michonne Middy Milo Mittens Moe Moxie Muffin Mya Myla Nellie Nelson Noel Noodle Nova Oakley OLI PATTY PIPER Podge Quill QUINT Randi Reuben Rhonda Riggs Roberta Rocky Rome Romeo Rosita Rowen (Sponsored Fee/longterm resident) Rudy Sabrina Sebastian Shadow Shontell Simba Smokey Sonya Story Superman Tami Teddy Theresa TIMMY Toby Keith Todd Velvet Vicki Wild Bill Wilson Yolanda

ADOPTION FEE:

TAG # AND YEAR

CLINIC:

AVC PET ID#:

MCHS REP: