I Want to Adopt

Midland County Pit Stop Pet Adoption Application

* Indicates required field

Date: *

Pets Name: *

FOR OFFICE USE ONLY
Payment Date
Payment Amount
Form of Payment
Additional fee for debit/credit card payment

Adoption Applicant Information

Name: First, Middle and Last *

Birthdate *

Physical Address *

City *

State *

Zipcode *

Most Recent Previous Address *

City *

State *

Zip Code *

Day Phone *

Cell Phone *

Email *

References

Please provide three references who are not considered family or living with you.

First and Last Name *

Phone Number *

Current/Previous Pet Info

Have you ever owned a dog or cat? *

Yes No

Do you currently have pets? *

Yes No

Type/Breed/Name/Age/Veterinarian Info/Spay/Neuter/UTD *

Home/Family Information

Number of adults living in your household *

Number of children in your household *

Spouse/Roommate's Name (First, Middle and Last) *

Birthdate of Spouse/Roommate(s) living in the house *

I give Midland County Pit Stop permission to do background checks on all adults in the home. ******PLEASE INITIAL****** *

Do you rent or own? *

Rent Own

If you rent, please list your landlord's first and last name *

Landlord's Phone Number *

Which best describes the area you live? *

City Suburb Rural

How long have you lived at this address? *

Do you have a yard? *

Yes No

Is it fenced? If so, how high is the fence? *

Primary Pat Caretaker is *

Other - please specify *

What hours primary caretaker is home *

In the event the main caretaker is unable to care for the pet, what are your plans for the pet? *

Do any of your household members suffer from pet dander related allergies? *

Yes No

Do you need your pet to be *

Dog Friendly Cat Friendly Child Friendly

Are there specific breeds you prefer or have experience with? *

Care Plan

Will this pet be kept *

Indoor Outdoor Both

Where will your new pet stay when you are home? *

Where will your new pet stay when no one is home? *

How many hours a day will your pet be alone? *

Where will your new pet stay when you are out of town or on vacation? *

If you do not have other pets, how will you socialize your new pet? *

Home visits are required prior to adoption approval and placement by an adoption liaison. **PLEASE INITIAL** *

Veterinary Care

Where will you vet your new pet? *

Are your current pets on preventatives? *

Yes No

Tell us about your experience with pets

Comment *

Have you ever surrendered a pet to Animal Control, a Humane Society, Rescue or individual? *

Yes No

If Yes, please explain *

Once the pet you are applying to adopt is deemed adoptable by the Adoption Liaison, you may begin the adoption process. *****PLEASE INITIAL***** *

**If for any reason you are unable to care for or keep the adopted animal, contact Midland County Pit Stop. **

PERSONAL OR PROPERTY DAMAGE AND/OR INJURY I acknowledge and agree that if the adopted animal bites or causes other injuries to humans and other animal, I will not hold Midland County Pit Stop of Midland Michigan responsible. I understand that all animals can carry and transmit diseases, including zoonotic diseases that can be transferred from animals to humans. I understand that Midland County Pit Stop will not be responsible for any damage the adopted animal may inflict on another person, another animal or any property, or for the transmission or transfer of any disease or parasite to other animals or people in the household. No attempt(s) will be made by me or anyone on my behalf to hold Midland County Pit Stop responsible. I hereby release Midland County Pit Stop and its agents, representatives/liaisons, and volunteers, and agree to indemnify and hold same harmless from any and all actions, causes of action, suits, debts, dues, accounts, covenants, agreements, judgements, claims and demand of any nature whatsoever arising out of my adoption of a pet from Midland County Pit Stop. I understand that if I am approved as an adoptee to a pet, I must abide by this agreement and that this agreement applies to any and all dogs/cats that I adopt from Midland County Pit Stop. *****PLEASE INITIAL***** *

Adoption fees are non-refundable. ****PLEASE INITIAL**** *

** A Signature will be required upon approval of Application**

Signature *

Date *

APPROVED BY (Midland County Pit Stop Foster Liaison) *

Date *

Submit

Midland County Pit Stop Pet Adoption Application

FOR OFFICE USE ONLY Payment Date Payment Amount Form of Payment **Additional fee for debit/credit card payment**

Adoption Applicant Information

References

Current/Previous Pet Info

Home/Family Information

Care Plan

Veterinary Care

Tell us about your experience with pets

FOR OFFICE USE ONLY
Payment Date
Payment Amount
Form of Payment
Additional fee for debit/credit card payment