MIDLAND COUNTY PIT STOP
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Midland County Pit Stop Pet Adoption Application
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Indicates required field
Date:
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Pets Name:
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FOR OFFICE USE ONLY
Payment Date
Payment Amount
Form of Payment
**Additional fee for debit/credit card payment**
Adoption Applicant Information
Name
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First
Last
Physical Address
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City
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State
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Zipcode
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Most Recent Previous Address
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City
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State
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Zip Code
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Day Phone
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Cell Phone
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Email
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References
Please provide three references who are not considered family or living with you.
First and Last Name
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First and Last Name
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First and Last Name
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Phone Number
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Phone Number
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Phone Number
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Current/Previous Pet Info
Do you currently have pets?
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Yes
No
Have you ever owned a dog or cat?
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Yes
No
Type/Breed/Name/Age/Veterinarian Info/Spay/Neuter/UTD
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Home/Family Information
Spouse/Roommate's Name
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Number of children in your household
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Number of adults living in your household
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Do you rent or own?
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Rent
Own
If you rent, please list your landlord's first and last name
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Landlord's Phone Number
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Which best describes the area you live?
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City
Suburb
Rural
How long have you lived at this address?
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Do you have a yard?
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Yes
No
Is it fenced? If so, how high is the fence?
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Primary Pet Caretaker is
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Employed full time
Employed part time
Retired
Stay at home or work from home
College Student
Check all that apply
Other-please specify
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What Hours Primary Caretaker is home
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In the event the main caretaker is unable to care for the pet, what are your plans for the pet?
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Do any of your household members suffer from pet dander related allergies?
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Yes
No
Do you need your pet to be
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Dog Friendly
Cat Friendly
Child Friendly
Are there specific breeds you prefer or have experience with?
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Care Plan
If you do not have other pets, how will you socialize your new pet?
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How many hours a day will your pet be alone?
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Where will your new pet stay when no one is home?
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Where will your new pet stay when you are home?
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Where will your new pet stay when you are out of town or on vacation?
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Home visits are required prior to adoption approval and placement by an adoption liaison. PLEASE INITIAL
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Have you ever surrendered a pet to Animal Control, a Humane Society, Rescue or individual?
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Yes
No
If Yes, please explain
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Veterinary Care
Where will you vet your new pet?
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Are your current pets on preventatives?
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Yes
No
Tell us about your experience with pets
Comment
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Once the pet you are applying to adopt is deemed adoptable by the Adoption Liaison, you may begin the adoption process PLEASE INITIAL
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Will this pet be kept
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Indoor
Outdoor
Both
**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.
**Signature will be required upon approval of Application
Signature
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Date
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APPROVED BY (Midland County Pit Stop Foster Liaison)
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Date
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Submit
Home
About
Adopt Me!
K-9
Feline
Forms
I Want to Adopt
I Want to Foster
Surrender My Pet
Find a Foster for My Pet
I Want to Help!
Donate
CommUnity
Event Calendar
Contact