First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County

Email*

Home Phone

Work Phone
x

Cell Phone*

Text/Pager Email

Are you 21 years or older?

What is your occupation?*

Animal Name and Number you wish to adopt*

Why are you interested in adopting a pet at this time*

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

For cats only: Do you understand that you must never declaw your adopted cat or kitten?
Choose one: Yes No

How many adults live in your home?*

Are there children in the home? If so please list the ages.*

Please list all the pets in your home. Include breed and age of each pet*

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

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, have you received the approval of your landlord to have an animal? If you own, please select NA.*
Choose one: Yes No NA

For Dogs, do you have a fenced yard ? If not how many walks do you plan on going on a day?

Current Veterinarian's Name and Phone Number (or one you plan on going to if you currently do not own a pet.)*

(Volunteer, Foster, Adopter) hereby agrees to hold Rebels Rescue, their officers, prior and current Directors, family members, harmless for any and all claims and agrees to waive all rights of subrogation against Rebels Rescue.