CCHDR Adoption Application
All the information below must be supplied in order to be considered for adoption. An incomplete application may be delayed or rejected.
Dog of Interest
First name
Last name
Date of Birth
Spouse / Partner's Name
Date of Birth (Spouse)
Address (House Number, Street, City, State & Zip Code)
Phone Number
Email
Are you (check one)?
Working
Retired
Attending School
Homemaker
Other
Place of employment (if working) and how long have you worked there?
Do you own your home?
Select an option
Yes
No
REQUIRED IF RENTING: Landlord Name and Phone Number (you must supply the actual property owner's contact information and fill out the Landlord Permission Form, separately)
Type of Residence?
House
Apartment
Condo
Mobile Home
Other
How long have you lived at this residence?
Are there other adults that live in the home? Provide their name(s), DOBs and relationship to adopter
Are there children in the home?
Select an option
Yes
No
How old is the child(ren)?
Are any household members allergic to pets? If "Yes," please explain who is allergic and the nature of the allergy:
Amount of time you or another adult is usually home (check one)?
Home all day
Out part-time
Away 7-10 hours daily
Other
If you checked "OTHER" (above), please explain:
Who will be responsible for the dog's training and exercise? What type of training and exercise will you provide? How often?
How long have you been looking for a dog?
Just started
3 - 6 months
1 year (+)
What type of vehicle and where IN the vehicle will you transport your dog?
Number of hours dog will be left alone daily?
0 - 1
2 - 4
5 - 7
8+ / other
If you checked "8+/OTHER" (above), please explain:
Where will the dog be kept when left alone?
Where will the dog be kept primarily during the day?
House
Yard
Crate
Garage
Other
If you checked "OTHER" (above), please explain:
Where will the dog be kept at night?
House
Yard
Crate
Garage
Other
If you checked "OTHER" (above), please explain:
Do you have a fenced yard? If "YES," describe the type of fence and height at lowest point:
Which of the following best describes your reasons for wanting this dog (select all that apply)?
Companion
Search and Rescue
Guard Dog
Agility
Hunting
Jogging
Obedience Training
Walking Buddy
Couch Warmer
When it comes to dogs, I tend to be more (check one)?
Strict / Demanding (dog must learn and follow all commands)
Moderate (encouraging of good behavior)
Lenient (wishy-washy, easily coerced by dog)
The noise / activity level in my home is usually:
High
Medium
Low
I would enjoy brushing or grooming my dog:
Rarely
Occasionally
Daily
Weekly
Monthly
I would prefer a dog that:
Enjoys walking with me on a leash
Exercises him/herself in our yard
Enjoys going to the dog park
Will run, jog, hike with me
Requires only enough exercise to do his/her business
Dog experience:
First time owner
Have had dogs in the past
Experienced
My ideal dog would:
Bad habits that I cannot tolerate include:
Under what circumstances would you not keep this dog?
CURRENT PETS: please include name / species / breed / age / sex / spayed or neutered?
FORMER PETS (within last 4 years you no longer own): please include name / species / breed / age / sex / spayed or neutered? / how long owned? / what happened?
Name and city of the veterinarian or vet clinic you use:
Who is designated as responsible for your dog(s) if you are on vacation, have an emergency, or can no longer care for your animals?
Please include any additional information, questions, comments or special circumstances you think we should know about (not captured elsewhere in the application):
DISCLAIMER & APPLICANT SIGNATURE
This Voluntary Release/Waiver of Liability (the Release) is made and entered into between the undersigned and Central Coast Herding Dog Rescue (CCHDR) effective as of the below-indicated date. The undersigned desires to adopt and/or foster an animal from CCHDR, and as an inducement to CCHDR to agree to the adoption and/or foster, the undersigned hereby represents, acknowledges and agrees as Follows: * I acknowledge that, due to the unpredictable nature of animals, certain risks and dangers may occur while caring for an animal, including risks of injury to person and property, and that I have voluntarily agreed to make the adoption and/ or foster contemplated herein with full knowledge of such risks and hereby voluntarily assume all of such risks. * I agree that I will not make any claims against, sue or attach any property of CCHDR, its directors, officers, agents, employees and/or volunteers, including, without limitation, CCHDR, for any injury or damage caused by any animal(s) adopted or fostered from CCHDR. Any actions against CCHDR will take place in San Luis Obispo County, CA. * I hereby voluntarily release, discharge, waive and relinquish any and all actions or causes of action for personal injury, property damage or wrongful death occurring to me or third parties as a result of any action or activity of any animal(s) adopted or fostered by me from CCHDR, wherever and however the same may occur which I may have against Rescue or any of its directors, officers, agents, employees or volunteers, including, without limitation, Central Coast Herding Dog Rescue, whether the same shall arise by the negligence of said persons or otherwise. IT IS MY INTENTION BY THIS INSTRUMENT TO EXEMPT AND RELIEVE RESCUE FROM ALL LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR OTHERWISE. * I hereby agree to hold CCHDR and its directors, officers, agents and/or employees, including, without limitation, harmless and indemnity them from and against any liability claims, judgements or expenses I may incur arising out of my adoption or foster of an animal from CCHDR and/or my ownership or care of any such animal Thereafter. * I agree that in the event I can no longer provide a safe environment for the dog being adopted or fostered, I will consult with CCHDR and return the dog if requested to do so. * I HAVE CAREFULLY READ THE FOREGOING, AND I UNDERSTAND THAT TOGETHER THEY CONSTITUTE A DISCLAIMER OF LIABILITY BY CCHDR AND A RELEASE OF ALL CLAIMS BY ME. I UNDERSTAND THAT I ASSUME ALL RISKS INHERENT IN MY DECISION TO ADOPT OR FOSTER AN ANIMAL FROM CCHDR AND ANY RELATED ACTIVITIES. I VOLUNTARILY SIGN BELOW TO EVIDENCE MY ACCEPTANCE OF THE ABOVE PROVISIONS. * If any portion of this Release is held invalid, it is agreed that the balance thereof shall continue in full legal force and effect. * This Release is governed by laws of the State of California applicable to agreements entered into and fully performed therein.
Your Signature
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Clear
Printed Name
Date
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