Adoption Matchmaker Application

Adoption Matchmaker Questionnaire

Name of Animal you would like to adopt. *Please fill out one form per animal you'd like to adopt, if you're unsure please first call AVHS staff at 719-395-2737**

How did you first hear about this animal?

Name*

As displayed on driver's license

First Last

Today's Date

Names of other adults in your household

First Last

Names of other adults in your household

First Last

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing Address

If different from physical

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Alternate Phone

Email*

Would you like to receive email updates?*

Yes, please sign me up!
No thank you

Are you 18 or older?*

Yes
No

Home

How many adults live in your home?*

How many children live in your home?*

What are the children's ages?

Describe your household:*

Quiet
Calm
Active
Noisy
Other:

If you marked other, please define:

Are you aware of any restrictions from your landlord, HOA, city, or county that would prevent you from adopting this animal?

Yes
No

If you are renting what is your Landlord's name?

If you are renting what is your Landlord's Phone number?

Pets

Have you adopted from us in the past?*

Yes
No

Do you currently have any pets?*

Yes
No

How many pets and what types?

Lifestyle

Approximately how many hours will your pet be alone each day?*

Do you have guest at your home often?*

Yes
No

Do guests bring their pets over to your home often?*

Yes
No

Where will your new pet spend its days?*

Tied Outside
Crated
With me
Bedroom/basement/bathroom
Inside
Kennel Run
Barn
Fenced Yard

Where will your new pet spend its nights?*

Free Roaming
Tied Outside
Crated
With me
Bedroom/basement/bathroom
Inside
Kennel Run
Barn
Fenced Yard

Are you considering physically altering your newly adopted pet (declawing, cropping ears, etc.)*

Yes
No

If yes, which one:

Upload Photo of your Drivers License or ID

Max. file size: 64 MB.

Please Initial Below

PLEASE READ THE FOLLOWING STATEMENTS. INITIAL EACH PARAGRAPH IN AGREEMENT OR, IF YOU DISAGREE WITH OR HAVE QUESTIONS ABOUT A STATEMENT, CONSULT WITH THE ADOPTION COUNSELOR.

I agree to provide this adopted pet with good care, including but not limited to healthy food, clean water, warm shelter in a loving, humane home, grooming, training and adequate exercise.*

(Dog only) The dog will be safely and humanely contained when on my property. The dog will not be tied or chained for extended periods of time. Nor will the dog be permitted to run-at-large in the community.*

I will take the animal to the veterinarian for booster vaccinations if needed, as well as routine examinations and immunizations. I will have the animal treated immediately for any illness/injuries. I acknowledge and agree that I am responsible for any and all veterinarian and medical expenses upon adoption of the animal and that Ark-Valley Humane Society (AVHS) is not financially responsible for any expenses after adoption.*

I understand that AVHS has made a good faith effort to ensure my pet is in good health or has disclosed any known health conditions. I understand that it is possible that an illness or injury, or the extent of an injury, may exist and be unknown at the time of adoption. I understand that I will be given AVHS’s health record for the adopted pet at the time of adoption, whether verbally or in writing. I agree to share this record with the pet’s veterinarian. AVHS strongly recommends that within two weeks of adoption, the adopted pet is seen by a veterinarian for a general health exam. If an illness or injury is discovered after adoption, I understand that my sole recourse, if I choose to not pay for the pet’s medical expenses, is to return and surrender the animal to AVHS, and AVHS will make all further decisions regarding the pet’s care after that time.*

I understand and agree that the actions of animals are unpredictable. I understand that an animal’s behavior may change after it leaves the shelter and accustoms itself to a home or other environment, and that AVHS makes no guarantees or warranties, express or implied, as to the age, breed, temperament, health, behavior, prior experiences or mental disposition of any animal put up for adoption. I accept all responsibility for all interactions with people and other animals.*

I understand I have 30 days to exchange this animal for a voucher that will apply the fee at the time of the adoption towards the adoption of another animal. AVHS reserves the right to refuse to extend the offer of a voucher.*

I will not physically, mentally, or emotionally abuse or neglect the animal or allow it to be abused or neglected. I authorize AVHS, at its sole discretion, to determine whether or the animal has been abused or neglected while in my possession and to reclaim the animal.*

I agree to adhere to all relevant zoning and animal control codes, and all relevant ordinances, whether local, City, county, or state of Colorado.*

AVHS reserves the right to perform a home inspection at any time prior to adoption.*

In the event the adopted pet becomes lost, I will immediately notify AVHS. I will immediately notify AVHS of any change of contact information (address, phone number(s), or email address). I authorize any individual or agency to release the animal back to AVHS if it is found abandoned, running at large or is brought to a shelter facility for any reason.*

Risks are involved in adopting a shelter pet. I acknowledge and agree that animal bites or other injuries to humans, property, and other animals occur and that all animals can carry and transmit parasites, diseases, including zoonotic diseases that can be transferred from animals to humans. I shall indemnify, defend, and hold harmless AVHS and its officers, directors, agents, volunteers, and employees from and against any and all liability, damage, loss, cost, and expense incurred as a result of any injury or loss, including, without limitation, any bodily injury or property damage to me, my family, others or other animals arising out of my adoption of the animal or any other activity I engage in related to AVHS.*

I agree that adopted pets may not be sold or surrendered except to AVHS or another no kill or minimal kill shelter, or to a home well suited to the pet’s needs. If I do rehome my pet, I agree to notify AVHS of the change in ownership. My pet may be returned to AVHS at any time. If I have owned my pet for more than six months, I may be asked to pay a surrender fee. I understand that adopted pets may not be euthanized for non-medical reasons without first consulting with AVHS staff. I understand that pets may not be adopted for experimental purposes, human consumption, unlawful activities, or for consumption by another animal. Pets may not be adopted for purposes of being offered as prizes in raffles or drawings. I agree to not cosmetically alter this animal (declawing,cropping ears, docking tails, etc.).*

I affirm that no member of my household has been convicted or charged with any animal welfare law violation such as hoarding, unsanitary conditions, neglect, cruelty, abandonment, etc. I affirm that no member of my household has been convicted or charged with any domestic battery or sex crime.*

I am at least 18-years of age and have the full consent of all adults in the household to proceed with this adoption.*

By signing below, I further agree to indemnify and hold harmless AVHS, its officers, directors, agents, volunteers and employees, from all claims or demands of any nature whatsoever (including attorney’s fees) made by any third party which arise out of or relate to my adoption and/or any other activity I engage in related to AVHS.*

AVHS is not liable for any claims, legal actions, losses, injuries, damages, costs, expenses, or liabilities whatsoever in connection with my care of an adopted pet, including, but not limited to, losses, injuries, damages, costs, expenses, or liabilities incurred by members of my family, neighbors, other animals or others that might enter my home.*

I agree, without protest, to reimburse AVHS for all actual and reasonable expenses incurred by way of my violation of any term or provision of this Agreement, including, but not limited to, reasonable attorneys’ fees and costs.*

This Agreement is made pursuant to and governed by the laws of the State of Colorado. This Agreement represents the entire agreement of the parties as to the subject matter contained herein, and may not be amended except by in writing executed by all of the parties. This Agreement shall be binding upon and inure to the benefit of the respective heirs, successors and assigns of each of the parties hereto. In the event any one or more of the provisions of this Agreement is held to be invalid, illegal or unenforceable in any respect by any court or other entity having the authority to do so, the validity of the remaining provisions hereof shall in no way be affected or disturbed.*

I acknowledge that the statements contained within this Agreement are true to my knowledge and further acknowledge that the representations made herein are material to AVHS’s consideration of this Agreement and that AVHS will rely on the truth of the statements made herein. If any information contained herein is deemed to be falsified by AVHS, I agree to immediate surrender of the animal to AVHS, at my sole expense.*

Signature*

I hereby acknowledge that I have read and understand each statement listed above. I have initialed each statement in full agreement of the terms outlined in this adoption contract. By signing this contract, I acknowledge that I am the intended owner of the pet and have received a copy of the Rabies Prevention Informational Brochure.

Date

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719-395-2737

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Adoption Matchmaker Questionnaire

Adoption Matchmaker Questionnaire

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