Safe Haven of Iowa County

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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County*

Email*

Home Phone*

Cell Phone

What is your preferred method of communication?*
Choose one: Email Phone Text

How long have you lived at your current address?*

Which animal are you interested in?*
Choose an animal: Baby BeckyJo Diego (Bonded w/ Dora) Dora (Bonded w/ Diego) Erebos (Courtesy Listing) Gus (aka Apollo) Jinx Lola Lottie Meredith Grey Mila Paisley Pearl (fka Tiny Tot) Presley Ribsy Salem Sandor Sugar Sweets Sylvie Tora Witten

If the animal you are interested in is not listed on the website, please add their name here.

Why are you interested in adopting a pet at this time?*

Are you at least 18 years of age?*
Choose one: Yes No

In what type of home do you live?*
Choose one: Single Family Mobile Home Apartment Townhome Other

If you answered "Other" to the previous question, please explain.

Do you own or rent your home?*
Choose one: Own Rent Live with Parents Other

If you answered "Other" to the previous question, please explain.

Does your city and/or county have any breed bans in place?*
Choose one: Yes No Unsure

If you rent, have you checked with your landlord to see if there are any restrictions on pet ownership and/or weight limits for animals in the residence?*
Choose one: Yes No N/A

We require your landlord's permission to have an animal in their residence. Please provide your landlord's first and last name along with their phone number.

Are you willing to allow a representative of Safe Haven of Iowa County to complete random home inspections throughout the pet's stay?*
Choose one: Yes No

Have you ever applied to adopt or adopted from Safe Haven of Iowa County before? *
Choose one: Yes No

If "Yes", what was the approximate year and date?

Have you applied to adopt or adopted with any other rescues or shelters?*
Choose one: Yes No

If "Yes", please tell us when and what shelter you applied to adopt or adopted from.

How many people reside in your household?*
Choose one: 1 2 3 4 5 6 >6

If any children are under the age of 18, what are their current ages?

Do you currently own or live with any pets? *
Choose one: Yes No

If so, please list the name, species (cat, dog, reptile, barnyard, etc.) of each pet, and who is responsible for the veterinary care of that animal.

Excluding your current pets, have you previously owned any other animals? *
Choose one: Yes No

If “Yes”, where are these animals now?

What is your veterinarian's office name, city, and phone number?*

Could your pets be listed under another person's name at the veterinarian's office?*
Choose one: Yes No N/A

If so, what is that person's name?

Are your current pet(s) spayed/neutered and up to date on the rabies vaccination?*
Choose one: Yes No N/A

When was your pet(s) last seen by a veterinarian?*

What was the reason for your pet's last visit to the veterinarian?*

What is your plan for relocating with your pet(s)? For example, moving with a job, new house/apartment, etc.*

Who will be the primary caretaker for the pet? Who will care for the pet if you are unable to?*

Are you aware that in the first year alone, veterinary care and preventatives for an adult dog can cost ~$500 and care for a puppy can cost upwards of $700?*
Choose one: Yes No

Are you aware that dog obedience training can cost ~$1000 for 6 sessions, annual food cost is ~$600, and if needed, grooming can cost upwards of ~$75/visit?*
Choose one: Yes No

Are you aware that adopting an animal is a lifetime commitment and they can live up to ~18 years?*
Choose one: Yes No

Do you, any member of your household, or anyone who visits regularly have any pet allergies?*
Choose one: Yes No

If "Yes", what precautions will you take when that person is in your home?

What type of fence is around your yard?*
Choose one: Privacy Chain Link Underground No Fence

What is the height of the fence?
Choose one: 4 foot 6 foot 8 foot N/A

Please provide a name, phone number, and relationship of one family member that we may contact as a reference. Preferable someone who does not live in the home where the pet will live.*

Please provide the name and phone number of two personal references; people who are not family members nor your veterinarian. *

Please let your references know that our volunteer may be calling them so that our calls are answered.

How much time will the pet spend alone during the day?*

Where will the pet be kept when you are home? And when you are away?*

Where will the pet sleep?*
Choose one: Indoors Outdoors

Tell us about your daily routine and how a pet would fit into it.*

Where would your pet go if you were away from home for an extended period of time? (For example, on vacation, hospital stay, longer than 3 days, etc.).*

How would you handle challenges related to training or behavioral issues? (For example, barking/whining, chewing, resource guarding, urinating/defecating in the house, etc.).*

What are your plans for providing exercise and/or mental stimulation for your pet? (Please list any parks nearby or trails, how many walks/day, approximate length, or alternate activities).*

What type of identification do you plan to place on your animal?*

It may take your new pet two weeks or more to adjust to its new home; are you prepared to allow your new pet time to adjust to its new surroundings?*
Choose one: Yes No

What will you do to help your new pet adjust to its new home?*

How did you hear about Safe Haven of Iowa County?*

Are you interested in how you can become a volunteer with Safe Haven of Iowa County?*
Choose one: Yes No

Have you, or any other member of your household, ever been arrested, charged or convicted of any animal-related crime such as failure to provide adequate care, animal cruelty, animal abandonment, animal neglect or any crime of moral turpitude?*
Choose one: Yes No

Disclosure and Release Clause

I, the undersigned, do hereby declare that I am aware:

1. The actions of animals are often unpredictable.
2. Animals should be closely supervised when they are with children.
3. An animal's behavior may change after it leaves the shelter and accustoms itself to a home or other different environment.
4. Safe Haven of Iowa County makes no claims or representations as to the temperament, health or mental disposition of any animal put up for adoption.
5. Safe Haven of Iowa County is not held liable for conditions arising from the adoption of an animal.
6. THE ADOPTING FAMILY DOES HEREBY RELEASE, DISCHARGE AND HOLD HARMLESS SAFE HAVEN of IOWA COUNTY AND ANY PERSON, FIRM OR CORPORATION CHARGED OR CHARGEABLE WITH LIABILITY TOGETHER WITH THEIR HEIRS, ADMINISTRATORS, EXECUTORS, SUCCESSORS AND ASSIGNS FROM ANY AND ALL CLAIMS, DAMAGES, COSTS, EXPENSES, LOSS OF SERVICES, ACTIONS OR CAUSES OF ACTION, WHETHER KNOWN OR UNKNOWN, BELONGING TO THE FAMILY DUE TO ANY ACTION OR OCCURRENCE ARISING OUT OF OR IN CONNECTION WITH THE ADOPTION OF A PET FROM SAFE HAVEN of IOWA COUNTY.
7. I agree to abide by all city and county animal control ordinances, specifically any leash laws to prevent the animal from roaming and becoming a nuisance animal.
8. It is expressly understood that such animal is NOT to be sold, traded, or given away for any purpose. It is not to be abandoned. IF I CANNOT PROVIDE FOR THE ANIMAL ANY LONGER, I WILL RETURN IT TO SAFE HAVEN OF IOWA COUNTY.
9. Adopter agrees that, without liability, Safe Haven of Iowa County may investigate the adopter’s home and the conditions under which the animal is being kept, and may take possession of the animal, if in the opinion of Safe Haven of Iowa County, it is receiving less than adequate care, is being improperly housed or handled, or if any other condition of this contract is being or has been violated. In the event the adopter fails or refuses to return such an animal upon demand, the adopter hereby agrees to pay reasonable attorney’s fees in the event an attorney is consulted or if suit is brought for the return of the animal.
10. The adopter acknowledges reading and understanding all policies within this contract and accepts this animal as a pet and companion and willfully accepts the terms outlines within this legally binding agreement.

Please select "Yes" to acknowledge your agreement of this Disclosure and Release Clause. *
Choose one: Yes No

I certify that the information entered on this application is true (enter your name and date).*

Please check the box below that you are not a robot before submitting.