Adopt a Pet Dog Adoption Application Portage APL Dog Adoption ApplicationWe reserve the right to deny any adoption.Name* First Last Phone*Best number to contact you at.Email Address* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Today's Date* MM slash DD slash YYYY The date you are filling out this application.Adoption Consent & Requirements*I understand that in order to be considered for an adoption from Portage APL, I must: - Be at least 18 years of age - Have the knowledge and consent of all adults living within my household - Have proof of landlord's consent to bring an animal onto the property I agree to these adoption requirements.Name of the dog you are interested in adopting: How many people live in the home?*1234567891011+Do you have a fenced-in yard or area? Yes No No, but we are having one installed Are there children in the home or that visit the home?* Yes No HiddenIf yes, please list ages of children:* How often are children in the home?* Have younger children (ages 10 and under) in the home been taught how to properly interact with dogs?* Yes No Is any household member allergic to dogs?* Yes No If yes, someone is allergic, how will they deal with reactions to this dog?*Why do you want to adopt a dog?* Companionship Child's pet Family pet Playmate Companion for another pet Guard Dog Gift Hunting Dog Other Please check all that apply.If 'Other', please explain: Are there other animals in your home?* Yes No If yes, tell us a little about your other animals.*(i.e. Type of animal, ages, personality, how long you've had them, etc.)Have you had a pet that had Canine Distemper, Parvovirus, any other contagious disease or has died from an unknown cause in the last six months?* Yes No Do you have a veterinarian that you visit regularly?* Yes No If yes, please give the vet's information:*Please include vet's name, name of their practice, phone number and address.What is your dog experience?* First time dog owner Owned multiple dogs Owned dogs who have required training Owned dogs with behavioral and training problems In the past have you owned dogs that have not worked out for you?* Yes No If yes, please explain:Do you know the life expectancy of a dog may be 15+ years? Are you willing to take responsibility for your dog's entire life?* Yes No Which best describes your living situation?*(Please check all that apply.) Renting a house Apartment Condo Live with parents Mobile home park Own my own home If renting, please list the name and phone number of your landlord: Who will be the primary caretaker of the dog?* If you should ever move or experience significant life changes, what would you do with this dog?* Where will the dog stay during the daytime (i.e. working hours)?* Where will the dog stay during evening hours?* Application Submission & Consent*This application is designed to help us determine if the adoption is in the dog’s best interest, and to assist you in finding a compatible pet for your lifestyle. An unwise adoption can result in an unpleasant experience for both the adoptive family and the pet and may ruin the pet for future adoption. We hope you agree that the pet’s welfare MUST BE OUR FOREMOST CONCERN. We reserve the right to examine the adoptive situation and decide what is best for the pet's overall quality of life. Our goal is to ensure a forever home for each pet that is adopted and a conducive life for the pet involved. I understand these goals and agree to them. I also understand that misrepresentation or omission of facts is cause for denial of adoption. I understand the above questions and I authorize investigation of all statements contained in the application. By signing this application, I am stating that the above mentioned is true. (Please initial below) Kennel Cough Liability Waiver*Kennel cough known medically as infectious trachea bronchitis, is a disease in dogs characterized by the presence of a dry or harsh cough. It results from an infection of the dog’s respiratory system, resulting in inflammation. Kennel cough is named as such because the disease can spread rapidly from one dog to another, especially when they live in the same quarters, such as in a kennel. Commonly, kennel cough presents as coughing, which may be associated with gagging or retching. Both viruses and bacteria can cause kennel cough. Most of the time, kennel cough is caused by more than one kind of organism. These organisms can be spread through the air and via direct and indirect contact with contaminated material. Portage Animal Protective League vaccinates all dog with Bordetella, a vaccine to help prevent kennel cough, however there are several strains. Shelter staff works very hard to ensure the health of your dog. By initialing below, you agree that Portage Animal Protective League is not responsible for any costs incurred due to kennel cough in your adopted dog, the transmission to owned dogs or any other dog. You also acknowledge the risks and responsibilities associated with adopting a dog with kennel cough or a dog with exposure to kennel cough. Dogs may not show symptoms of kennel cough for up to two weeks after exposure. During the first two weeks after adoption, you must watch for signs and symptoms and if necessary you must bring your dog to the veterinarian for diagnosis and/or treatment at your own expense. Please initial below: Release and Waiver of Liability*Release and Waiver of Liability: I understand that the Portage Animal Protective League makes no guarantee regarding the temperament, disposition or the training of the animal. I understand that based on an assessment of this animal, in the shelter environment, it has been determined that it has a possibility to bite. I agree that the Portage Animal Protective League shall not be held legally liable for any acts of the animal after it leaves the shelter. I agree that I fully acknowledge the risks of adopting this animal. I hereby release and discharge Portage Animal Protective League, its employees, agents, Board Members, donors and supporters for all acts and omissions, claims or causes of action of any kind arising from the adoption of this animal. By initialing below, you agree that you have fully read and understand this waiver and agree by these terms. Please initial below: NameThis field is for validation purposes and should be left unchanged.