State:    Zip:

Mailing Address  (if different from above):

City:  State:  Zip:

Phone Number:  Alternate Phone #:

E-Mail Address:  

Adopter's Age: Choose One Under 18 18 - 21 22 - 25 26 - 30 31 - 40 41 - 50 51 - 60 61 - 65 66+

Driver's License #:  DL State:

How do you plan on paying for the adoption? Choose One Cash/Check Cash Check Credit


Pet Information:

Name of pet you are interested in: 

Pet Gender: Choose One Male Female

Pet Type: Choose One Dog Cat Horse Goat Other Livestock Small Animal   This pet will primarily live?: Choose One Inside Outside

When not at home, where will your new pet be kept? 


Do you know what heartworms are? Choose One Yes No Sortof

Will you keep this pet on heartworm preventative? Choose One Yes No Why?

Some of our dogs will do MUCH better if adopted with another dog.  Is this something you would be willing to do?  Yes   No

Some of these pets may take extra time to adjust to their new home.  Are you willing to be patient and understanding? Yes  No, I just do not have the time to work with a dog that is not going to adjust quickly.


Household Information:

Do you have any other pets? Choose One Yes No  
If yes, please describe them.

If yes, are they spayed/neutered? Choose One Yes, Some of them Yes, All of them No

If yes, are they on heartworm prevention? Choose One Yes No Not Applicable What Kind?

Do you have a fenced in yard? Choose One Yes No No, but I am building one

If you do not have a fenced in yard, and you are planning to adopt a dog, are you willing to ALWAYS keep your dog on a leash when outside? Choose One Yes No Most of the time Why

Do you have children? Choose One Yes No   If yes, what ages?

Are any of the members of your family possibly allergic to the pet you are trying to

adopt? Choose One Yes No Maybe Not Sure

Do you have any additional comments or questions?  If yes, please type them in here:


Disclaimer:

I (Full Name)  understand that I am applying to adopt a pet at my own risk.  I understand that not all of these pets have been introduced to children.  In turn, if I adopt one of these pets, I understand that he/she may take some time to adjust to children.  I understand that there is even a chance that children may initially scare this pet and need to be watched carefully when around this pet.  I understand that once adopted, this animal will be solely my responsibility.  I also understand that if for ANY reason I decide that I do not want or cannot keep this pet after he/she has been adopted, I must return him/her to Regency Place.  I understand that I cannot give, sell, or adopt this pet out to anyone else.  I understand that whether I own the adopted pet for 5 days or 5 years, if returned, I am to expect no adoption fees or deposits to be returned/refunded to me under any circumstances. I acknowledge my awareness that all animals respond to situations differently and that such a response may be unpredictable.  I agree that Regency Place has not made, nor makes any claims, representations, or warranties, either expressed or implied, as to predict the behavior or temperament of the adopted animal in all situations.  I agree not to hold Regency Place or any of its representatives responsible or liable for any damages to persons or property that is caused by the adopted animal.  I agree that Regency Place is not financially or legally responsible for any medical or other expenses incurred by the adopted animal once the adoption papers have been signed. (Please initial in box.  By initialing, you are agreeing to and fully understand the above disclaimer)