Basic Information:

First Name:   Last Name:

Physical Address:City:

State:    Zip:

Mailing Address (if different from above):

City:  State:  Zip:

Phone Number:  Alternate Phone Number:

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 Credit
 

Pet Information:

Name of pet you are interested in:  Pet Gender: Choose One Male Female

Pet Type: Choose One Horse Goat Other Livestock Small Animal   This pet will primarily live?: Choose One In a pen In a cage In a fenced pasture

Will this animal have shelter from the weather?   Choose One Yes No   If yes, please discribe:

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


Household Information:

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

Are any of the members of your family allergic to this pet, its dander, or any components of its care (i.e. hay, cedar bedding, etc.) Choose One No Yes Maybe Don't Know

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 without written consent from Regency Place.  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)