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CEDAR RAPIDS ANIMAL CONTROL
PET ADOPTION
Potential Adoption Application




NOTE:  ALL ADOPTIONS ARE FIRST COME/FIRST SERVE.


 APPLICANT/CO-APPLICANT PROFILE
Each field is required.  Please type N/A if it doesn't apply to you.

First Name:     Last Name:       Age: 

Spouse Name:


Physical Address:


City:                  State:                  Zip Code: 

Home Phone:                  Work/Cell Phone:  

Email Address: 

Driver's License#:    Driver's License State: 

Do you Own or Rent your home?  

If you Rent, have you paid all pet deposits?  

Landlord name:

Landlord's Contact Info:

How long have you lived at this address?

Any plans to move in the near future?


What type of animal are you looking for?  

Enter Animal Name or ID # if known:

If you chose Other, please describe the animal you're looking to adopt:



FAMILY/HOUSEHOLD INFORMATION

Number of Adults in the household:

Relationships:

Number of Children in the household:

Ages of Children:


Have the children had pets before?  

Any allergies to pets?  

Why would you like to adopt an animal from us? (Select all that apply)
 Companion for self    For another household member    For a child
 For another pet    Guard/Protection    Gift    Other

If you chose Other, please explain:



 CURRENT/PAST PET INFORMATION

Do you currently have pets?        Is this your first pet?  

Please tell us about any pets that you have had in the past 5 years.
PET 1:
Name: Breed: Age: Sex/Status: 
Where is this pet now?

PET 2:
Name: Breed: Age: Sex/Status: 
Where is this pet now?

PET 3:
Name: Breed: Age: Sex/Status: 
Where is this pet now?

PET 4:
Name: Breed: Age: Sex/Status: 
Where is this pet now?

PET 5:
Name: Breed: Age: Sex/Status: 
Where is this pet now?

Have you ever give an animal away or relinquished an animal to a shelter?  
If yes, what were the circumstances?

Veterinarian's Name:               Veterinarian's Phone #: 

Current pet's last visit to the veterinarian and why:

Are your current pet's rabies vaccinations up-to-date?  

Please attach rabies certificate(s) here:
Please Initial Your Acknowledgement Here: 


NEW PET INFORMATION

How long have you been looking for a pet?
How much time are you prepared to allow for your new pet to adjust to your home?

Are you able to afford a bill of $200-$800 for emergency veterinary care?  

How much do you expect to spend on maintenance for your pet in a year?

Are you committed to providing a responsible home for your pet's entire life (10+ years)?  

If you have to move, what do you plan to do with your pet(s)?
Who in the household will be the pets' primary caregiver?
Where will the pet be kept during the day? (Be specific)
During the night? (Be specific)

Do you plan to let your cat outside?                        Do you have a fenced yard?  

Type of fence:

If you do not have a fenced yard, how do you plan to contain your pet outside your home?

How many hours per day will your pet be left alone?

Some of our animals are not fully grown.
Are you prepared for the potential size of your new pet and how it could affect your home?

What do you plan to do with your pet when you go on vacation?

New pets often develop (or have) bad habits, such as: digging, barking, chewing, separation anxiety, aggression, failure to house train, or failure to use a litter box. How do you plan to manage these situations?


 MEDICAL INFORMATION

There are yearly vaccines that your new animal needs to remain healthy. Required vaccines for dogs are the Rabies vaccine and DHPP/DHLPP (commonly known as distemper). Required vaccines for cats are the Rabies vaccine and FVRCP (commonly known as feline distemper). Please check with your veterinarian for their recommendations.

Are you aware of the costs involved and your responsibility for the veterinary care, food, heartworm, or FeLV/FIV and flea/tick preventative needs, and the housing of this animal?  

Please Initial Your Acknowledgement Here: 


PLEASE NOTE

Our goal is to place animals into permanent, caring, and loving homes. We will do what is best for the animal being considered for adoption. Some need county homes, some need adult-only homes, some need homes where they will not be left alone for long periods of time. Please understand that if you are refused, it is because it is in the best interest of the animal. We reserve the right to hold an application for 24 hours before adopting out an animal so that we may review it.

Please understand that Cedar Rapids Animal Care & Control is not a veterinary clinic and that this animal may be harboring a medical condition which is not apparent during its stay at the shelter, and that should such a condition become apparent after adoption, you assume full responsibility for any related veterinary care. We strongly recommend that you take your new pet to a veterinarian for a health examination within one (1) week of adoption.

Please Initial Your Acknowledgement Here: 


By signing (typing your name in the box) below, you have stated that all information on this application is true to the best of your knowledge. The Cedar Rapids Animal Care & Control has the right to refuse an adoption if it is found that information stated on the application has been falsified.

Please Type Your Signature Here:

Once you hit Submit, please wait for the form to process your responses.  This can take up to 15 seconds to complete, so please be patient.

     
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