KANSAS

Name of animal you are interested in

Name of Applicant

First

Last

Age

Name of Co-Applicant

Age of Co-Applicant

Driver's License Number and State

Address

City

State

Zip Code

Home Phone

Cell Phone

Email

Applicant's Employer and Phone Number

Position Title

Veterinarian's Name and Phone Number

Number of children in your home and their ages

Do the children live with you:

Full Time
Part Time

Number of Adults Living in Your Home (including applicant)

Is anyone home during the day?

Yes
No

Who will be responsible for caring for the animal?

Would you consider the location of your home to be

Urban
Suburban
Rural

Type of home

Do you own or rent? (If you rent you must prove that you are allowed to have animals and whether or not there are any breed restrictions?)

Rent
Own

Landlord's Name (if applicable)

How would you describe the activity level in your home?

Active
Moderate
Quiet

Do you have a fenced in yard?

Yes
No

If yes, what is the height of the fence?

If yes, how many gates do you have and how are they secured?

I have a:

Why do you want to adopt an animal?

Many rescued animals have been abandoned and may have behavioral and/or emotional issues. How are you and your family prepared to deal with these issues?

Will your animal be kept:

Indoors
Outdoors
Equally indoors and outdoors
Tethered outside

How long will the animal be left alone during the day?

When your animal is home alone will they be:

During the night your animal will be:

Please list any animals PREVIOUSLY owned (other than fish, rodents, and reptiles) and describe what happened to them.

What animals currently live in your home? Please list name, age, breed, how long you have owned them, their gender.

Are all vaccines up to date for animals living in your home? We will verify with your veterinarian.

Yes
No

Do you believe in spaying/neutering?

Yes
No

Are all animals in your home spayed/neutered? We will verify with your veterinarian.

Yes
No

An animal can depend on your for 14 years or more. Are you prepared for this commitment?

Yes
No

Have you ever given up an animal before? If yes, please explain why.

What types of behaviors would cause you to return your animal?

Are you willing to crate train to help with behavior issues?

Yes
No

Are you willing to attend behavior classes to help with behavior issues?

Yes
No

What will you do with your animal when you go on vacation?

What will you do with your animal if you move?

Under what circumstances would you return your animal

Please give the names and phone numbers of two references such as a neighbor or friend (no family members please).

Individuals who adopt from Critters 4 U Rescue Inc. are contacted periodically for an update to help ensure the animal successfully adjusts to its new home. If you adopt your animal from Critters 4 U Rescue Inc. will you consent to occasional contact to ensure your animal is doing well in your home?

Yes
No

I certify that I have never been convicted of animal cruelty, abandonment, neglect, or abuse.

Yes
No

If at any time an adopter cannot keep an animal, it must be returned to Critters 4 U Rescue Inc. By checking I Agree, I acknowledge that I have read this questionnaire completely, and comprehend the Adoption Application fully. I understand that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application of the adoption contract can result in forfeiture of the Critters 4 U Rescue Inc. animal adopted by me

Yes
No

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