Chelsea’s LegacyLouisville, KYAdoption Application



Chelsea’s LegacyLouisville, KYAdoption Application Animal’s Name: FORMTEXT ?????If necessary, describe the animal: FORMTEXT ?????All questions must be completedApplicant Information Full Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ???Date: FORMTEXT ?????LastFirstM.I.Address: FORMTEXT ????? FORMTEXT ?????Street AddressApartment/Unit # FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CityStateZIP CodeHome Phone:( )Cell Phone:( )Email Address: FORMTEXT ?????Employer: FORMTEXT ?????Work Phone:( )Your Birth Date (MM/DD/YY): Additional InformationHow did you hear about us? (To check the box, please double click mouse on box and mark under the section Default Value ‘Checked’) FORMCHECKBOX Paper FORMCHECKBOX Fundraiser FORMCHECKBOX TV FORMCHECKBOX Radio FORMCHECKBOX Friend FORMCHECKBOX FORMCHECKBOX Rescue Group FORMCHECKBOX OtherWhy are you adopting the pet? FORMCHECKBOX Guard/Watch Dog FORMCHECKBOX Companion FORMCHECKBOX Breeding FORMCHECKBOX Family Pet FORMCHECKBOX Gift FORMCHECKBOX Protection FORMCHECKBOX Hunting FORMCHECKBOX Companion for Other Pet FORMCHECKBOX Mouser/Barn Cat FORMCHECKBOX OtherFor whom are you adopting the pet? FORMCHECKBOX Self FORMCHECKBOX Children FORMCHECKBOX Spouse FORMCHECKBOX Other Family Member FORMCHECKBOX Family Outside Of Home FORMCHECKBOX Gift for Friend FORMCHECKBOX OtherWhere will your pet be kept (Check all that apply)? FORMCHECKBOX House FORMCHECKBOX Fenced Yard FORMCHECKBOX Garage FORMCHECKBOX Chain FORMCHECKBOX Kennel FORMCHECKBOX Farm FORMCHECKBOX Cable Runner/Tie Out FORMCHECKBOX Dog HouseDo you have a fenced yard? FORMCHECKBOX Yes FORMCHECKBOX NoIf you do not have a fenced yard, how will you supervise your pet when outdoors? (check all that apply) FORMCHECKBOX Leash FORMCHECKBOX Walk/Run FORMCHECKBOX Loose FORMCHECKBOX Kennel FORMCHECKBOX Cable Runner/Tie Out FORMCHECKBOX Live on Large Farm FORMCHECKBOX Rural Area FORMCHECKBOX Only Out When I’m OutIf adopting an outside dog, do you have a dog house? FORMCHECKBOX Yes FORMCHECKBOX NoCurrent Household PetsList all pets currently in your household (Type/Breed/Size/Age):Spayed/Neutered (Y/N)?Spayed/Neutered (Y/N)?Spayed/Neutered (Y/N)?Spayed/Neutered (Y/N)?If any of your current pets are not spayed/neutered, please explain why:Are your pets current on heartworm preventative and yearly vaccinations/boosters? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX SomeWhat is your experience with dogs/Cats? FORMCHECKBOX First-time Owner FORMCHECKBOX Have had 1 or 2 FORMCHECKBOX Knowledgeable/experienced FORMCHECKBOX Only Owned Cats FORMCHECKBOX Only Owned DogsPrior Pets in HouseholdPrior Pets in Household (Type/Breed/What happened to them – please be as specific as possible):Health/Wellness InformationDescribe any situations where you may have to return your adopted animal (job loss, children, moving, health, marital change, etc):If you move, what will you do with the pet? FORMCHECKBOX Take with You FORMCHECKBOX Return to Shelter FORMCHECKBOX Give to Friend FORMCHECKBOX Give to FamilyName of current/prior veterinarian:Phone #May we contact this veterinarian? FORMCHECKBOX Yes FORMCHECKBOX NoIf you have been with your current veterinarian 3 years or less, please provide contact information on the previous vet:Name of prior vet:Phone #May we contact this veterinarian? FORMCHECKBOX Yes FORMCHECKBOX NoWhat owner/name(s) are vet records listed under?Do you understand that a home visit is required?If your pet is sick or injured, what will you do?Do you agree not to have unnecessary surgery performed such as ears cropped, tails docked, and all four paw declawing (Y/N)?Do you agree to keep this pet current on all yearly boosters and rabies vaccinations (Y/N)?Do you agree to keep this pet on monthly flea and tick control (Y/N)?Have you previously adopted from Chelsea’s Legacy (Y/N)? If so, when/what?About Where You LiveType of Dwelling: FORMCHECKBOX House FORMCHECKBOX Apartment FORMCHECKBOX Mobile Home FORMCHECKBOX Townhouse FORMCHECKBOX Duplex FORMCHECKBOX OtherDescribe where you live: FORMCHECKBOX City FORMCHECKBOX Rural Area FORMCHECKBOX SuburbHow far away is your home from a busy intersection or highway?Do you: FORMCHECKBOX Own FORMCHECKBOX RentIf rent, landlords name and phone number: FORMCHECKBOX Live with Parent/Guardian (if so, please list name and phone number ):About Your FamilyAre there children in your household or ones who make regular visits to your home? FORMCHECKBOX Yes FORMCHECKBOX NoIf so, please indicate how many children and their ages:About This ApplicationDo you have any issues with us doing a follow-up call or visit after you have adopted? FORMCHECKBOX Yes FORMCHECKBOX NoIf you must give up the pet, do you understand that you have to return the pet to us or have us approve the possible home? FORMCHECKBOX Yes FORMCHECKBOX NoDo you understand that if any of the information in this application is found to be false, or if we find the animal you are adopting is not being given the proper care (personal or veterinarian), we may reclaim the animal? FORMCHECKBOX Yes FORMCHECKBOX NoPlease return completed application via email to fost228@or Mail to: P.O. Box 7035, Louisville KY 40257Thank you for your time and interest in helping Chelsea’s Legacy find perfect forever homes!For more information please visit our website at ................
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