H.A.R.T.

Homeless Animal Rescue Team

Tel: (435) 705-9835 / (435) 668-2655
Hartofutah@gmail.com

ANIMAL ADOPTION APPLICATION & AGREEMENT FORM

Name:_______________________________________________ Date:_______________________________
Address:_____________________________________________ Applicant’s Age:______________________

_____________________________________________ Email Address:_______________________

Do you wish to be added to our mailing list?________________

Telephone:___________________________________________

Name of dog interested in adopting:________________________________ Breed:_____________

Animals/ages in home at present time: Dog(s)?________________ Cat(s)?_____________________

Are these animals spayed or neutered? ____________________ If no, why not? _________________

If you have other pets, will they adjust to the new pet in the house? _____________________________

How many children are in the home? ________________________ Ages:_______________________

Name of your veterinarian:___________________________________________

Do you own your home or rent? ______________________

If renting, do you have permission to have pets? ______________ Landlord phone #:_______________

Do you have a dog or cat door? __________________

How long will the animal be left alone during the day ?___________________

Where will the animal be kept during the day:_______________ night:__________________

Is your yard fenced or gated? ___________________ Height: _____________ Type:_______________

If you do not have a fenced yard, how do you plan to exercise your new dog? _____________________

____________________________________________________________________________________

Will the animal be indoor as well as outdoor? ________________________________________________

In what situation would you consider giving up this animal? _____________________________________

What will happen to the animal if you were to move? ___________________________________________

Have you had pets in the past? ________________

What happened to the ones you no longer have:________________________________________________

______________________________________________________________________________________

We visit your home to insure a suitable environment for the animal. Do you object to such a visit? _______

What characteristics are you looking for in a dog? Please think about your lifestyle – are you active, or
are you more sedentary and quiet? What personality in a dog will best fit your family’s needs and lifestyle?

______________________________________________________________________________________

______________________________________________________________________________________

TERMS OF ADOPTION

The adoption donation fee for most of our dogs is $100, which helps to partially defray the veterinary expenses
incurred in rescuing the dog. All dogs will have been neutered or spayed, vaccinated (including a Rabies shot)
and given other medical treatment needed for problems that H.A.R.T. is aware of and can treat before adoption.
All adoption donation fees are non-refundable.

Return Policy: If I cannot keep the animal you are adopting for its lifetime, by signing this document I agree
to contact H.A.R.T. to discuss options. If the animal needs to be returned to H.A.R.T. it will be at my expense.
I agree to not euthanize this animal unless advised by my veterinarian for medical reasons.

Care: I agree to provide proper shelter, quality food, and proper medical care, i.e. necessary vaccinations
provided as advised by your veterinarian. I agree that this dog will not be allowed to run free without
supervision. I agree this dog will live in the house as a member of family and will not be chained or cabled in
the backyard. I agree not to allow this animal to ride loose in the back of a truck, or be used for guarding
purposes. I agree to obtain all licensing as required by local ordinances, and attach an identification tag to a
properly fitted collar on the animal at all times.

Liability: I understand that H.A.R.T. cannot guarantee the health or temperament of the adopted animal and
hereby release H.A.R.T., Board Members, volunteers, or any affiliates of H.A.R.T. from any claim, cause of
action or liability for any injury or damage to persons or property once the animal is in my possession. I agree
that if H.A.R.T. determines that any of these provisions have not been fully complied with I will return the
animal to H.A.R.T. on demand. If I fail to return the animal, H.A.R.T. shall have the right, without further
notice or demand to enter the premises where the animal may be, and remove the animal without process of
law. Adopter agrees to waive all claims of trespass or damage.

_________________________________ _____________________________
Signature of Adopter Date

_________________________________ _____________________________
Signature of H.A.R.T. Representative Date

Donation Received (non-refundable):___________________ Check Number:_______ Cash:_______