First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Work Phone
x

Cell Phone

How did you hear about us?

Which animal are you interested in
Choose an animal: Cosmo Dewey Draeco Gator King Strax

What is the most important trait you are looking for in a dog?*

Have you applied with any other rescue?
Choose one: Yes No

How did you hear about us

List two references -- Name and phone number (Not a family member)*

Veterinarian's Name and Phone Number (If you currently have a pet)

Are all members of your household in agreement with this adoption?*

Who in the household will care for the pet*

How many people reside in your household? List ages and sex of all member in household.*

In what type of home do you live
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Do you own or rent your home*
Choose one: Rent Own

If you rent, please enter your landlord's name and phone number

If you rent, have you received the approval of your landlord to have an animal
Choose one: Yes No

Is your yard fenced*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What is the height of the fence

What type of fence
Choose one: Privacy Chain Link Invisible

List all the pets you currently have in your home (breed, age and if they are spayed or neutered)

Where are these animals now?

Have you ever given up a pet? If yes, please explain*

What traits are you looking for in a pet

Would you consider a Dane mix breed?*

Would you consider a special-needs Great Dane?*

How much time will the animal spend alone during the day*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal be kept when you are not home*

Where will the animal be kept when you are home*

Where will the animal sleep*

Describe how you will train the pet*

I/we have voluntarily contacted Dane Haven and have expressed an interest in fostering a dog in the care and custody of Dane Haven. In consideration of Dane Haven’s agreement to allow me to view and/or interact with such dogs, I hereby, for myself, my heirs and my personal representatives, represent and warrant as follows:

1. I am fully aware of the risks that dogs pose and have elected to view and/or interact with one or more dogs in the care of Dane Haven voluntarily. I knowingly assume all risks that exposure to dogs may pose, including but not limited to, serious bodily injury and/or death. (place initials in box)*

2. I hereby waive, release, discharge, hold harmless, and promise to indemnify and not to bring suit Dane Haven, its directors, officers, volunteers, staff, and all other agents, and attorneys for any of the referenced parties, and any other parties acting for, or on behalf of any of the referenced parties, from any and all rights and claims which I have or which may hereafter accrue to me and from any and all damages which may be sustained by me directly or indirectly in connection with, or arising out of, my exposure to such dogs. (Place initials in box)*

By submitting this form, I hereby authorize the Doctor of Veterinary Medicine, named above, to disclose and/or release to Dane Haven, it's agents, successors or assigns, either verbally or in writing, complete information concerning his or her medical findings, treatments and records about any animals for which I have sought care and/or treatment from the so named Doctor of Veterinary Medicine. (***Please contact your vet to let them know we will be calling. They may require your permission before speaking with us. ***)

I certify that the information entered on this applicant is true. Enter your name and date*