706-692-2772    PO Box 45     Jasper, GA 30143

www.pickensanimalrescue.org           parinfo@pickensanimalrescue.org

Pickens Animal Rescue, Inc is pleased to provide you with the opportunity to adopt a pet. Any information provided by us about any of the available pets is accurate to our knowledge and belief at the time of the adoption. If this pet does not fit your lifestyle, it may be returned within the first 5 days. Your adoption fee can, and will, only be refunded upon request after the return of the pet. The pet has been seen by a veterinarian for Pickens Animal Rescue but you will need to schedule an appointment with a veterinarian for a routine health check. Their health records are provided to you at the time of adoption, and/or noted below for any discrepancies to this record.  This pet _______ has or ______has not been diagnosed with any medical conditions at this time.

PAR has observed the following health condition: __________________________________________________________________________________________________________________________________________________________________________________________

As the adopter, you assume all financial responsibility for any further medical expenses the pet requires. If you would like the original veterinarian to evaluate and make further recommendations, please contact them at _____________________________________________________________________________________________

Questions for adopters: (your honesty is appreciated and expected)

1. Number  of existing pets in your home __________Cats         __________Dogs
2. Are your current pets spayed and neutered? ________No ___________ Yes
3. Ages of children that will be living with the adopted pet _________________________________________
4. Do all family members agree to the adoption of this pet? ______yes  ________ NO (explain)___________
5. Where do your current pets stay when you are not home?  _______crate ________fenced yard ________loose inside the home ________daycare ______other (explain)___________________________
6. What is the name of your veterinarian clinic? _________________________________________________
7. Do you allow pets inside your home? _______________If not, what protection do they have outdoors? ______________________________________________________________________________________
8. Have you given up a pet in the past? ____yes   _____no   Why? __________________________________
9. Where will this pet stay the majority of the day? _____outside fence area  ____outside in a pen ___in a crate _______free run outside _________outside on a run or tie out  _________with you a work
10. How many hours will this pet be alone on a typical day? ___________
11. Have you ever had a pet with medical issues that caused you to give the pet up? Explain. ______________________________________________________________________________________
12. Which of the following reasons would you surrender your pet to a shelter? (circle all that apply)  _____moving  _____not housebroken  _____divorce  ____animal gets too large  _____shedding  _____allergies  ____barking ____aggressive _____medical problems  ____new baby _____children lost interest _____hard to contain in fence _______other (explain)________________________________
13. Do you live in a ________home  _____ apartment  _______rental home _________with family

To ensure your satisfaction and the welfare of the adopted pet, you as the adopter, agree to the following:

1. I agree to care for the pet in a humane and responsible manner as a member of my family, and to assume full responsibility for the pet’s well being for the rest of its life. 
2. To provide a well balanced diet and fresh clean water, clean and dry shelter, and daily exercise.
3. Not to keep the pet on leased or rented property where a “no pets” policy is in force.
4. To obey all applicable laws governing the control and custody of pets in your county/state.
5. To provide a safe collar with their rabies tag and I.D. tag with your name and phone number. AVID chips also acceptable.
6. I agree to NOT debark, crop, dock or otherwise surgically alter the pet for any non-medically necessary purpose. I also agree to not transport this dog in an open truck cargo area.
7. To provide all medical care and treatment needed by the pet including routine vaccinations, preventative heartworm medications, flea control, as well as care during illness or injury.
8. This pet is for a personal companion only, never to be used as a chained guard dog or for research purposes. I understand this is a rescue dog and that Pickens Animal Rescue makes no warranties, express or implied, about the pet’s health, behavior or temperament. Pets respond to situations differently and unpredictably.
9. I will allow a representative from Pickens Animal Rescue to visit my home to ensure that the terms of this agreement have been honored on a mutually agreed upon date as needed.
10. I agree to never turn this pet into a kill-shelter without first discussing options with Pickens Animal Rescue.
11. I understand I have the pet for a trial period of 5 days and that I may return the pet within this time period with a full refund.
12. I accept the liability for and responsibility to prevent damaging pet behavior for this pet. I agree fully and do completely release Pickens Animal Rescue, Inc. officers, volunteers, contractors and representatives, from any liability of any kind whatsoever arising from any health or temperament issues the pet may have or may develop, and /or from any and all claims relating to my adoption, ownership or possession of the pet.

Adopter verifies that he/she is 18 years of age or older and fully understands the contractual obligations set above.

Name: ______________________________________ Telephone ________________________

Address: ____________________________________  City, State, Zip ____________________

Email Address: _________________________________________________________________

Alternate Telephone: ________________________      Driver's License # __________________

Pet Being Adopted:    Cat   /   Dog                  Spayed/Neutered: Yes / No If No, Age of Pet: _____________

Name of Pet Being Adopted ______________________________________________________

Signature: ____________________________________Date: _________________

Foster Home Contact:_______________________________ Phone Number: _______________

Fee Collected $ _____________   Paid by:     Cash   /  Check                                              Check # _______________

Charge ($100.00) (see attachment for credit card transactions)          _________________________________

 White copy: PAR                              Yellow Copy:  Foster Contact                        Pink Copy: Adopting Family