Dog Application Form

Welcome! Thank you for choosing to adopt a pet from Kiya Koda Humane Society! We are excited to help you find the right companion for your family. The questions on this application are not a test. They simply help us learn more about you, your household, and your lifestyle so we can help make the best possible match.

Adopting a pet is a lifelong commitment.

We strongly encourage all members of your household, including any other pets, to meet the animal prior to adoption.

Kiya Koda Requirements:

You must be at least 18 years of age
All adults living in your household must be aware of the adoption and agree that the pet may live in the home
You must provide a valid form of identification showing your current address, or other acceptable proof of current address
Animals adopted from Kiya Koda Humane Society are adopted as family pets and may not be adopted for consumption, research, or any other purpose prohibited by our adoption policies
We require spaying of all females and neutering of all males
If you are unable to keep your adopted pet for any reason, the animal must be returned to Kiya Koda Humane Society. Adoption fees are non-refundable
Kiya Koda is not responsible for any illnesses, injuries, or veterinary expenses that may occur after the animal has been adopted
Kiya Koda is not responsible for any damage or injury caused by an adopted animal to any person, animal, or property after adoption
Sterilization of adopted animals is required pursuant to Iowa Code Section 162.20. A person who fails to satisfy the sterilization requirements may be guilty of a simple misdemeanor

Kiya Koda reserves the right to refuse any pet adoption.

Pet Name *

Section I — Adopter Information

General Information

Name: * {{ errors.name[0] }}

Date of Birth:

Cell Phone: * {{ errors.contact_number[0] }}

Work Phone:

Email: * {{ errors.email[0] }}

Address

Home Address:

City:

State:

Zip:

Emergency Contact (Outside of Your Household)

Name:

Phone Number:

1. Where do you live:

2. Do you:

Own

Rent

Live with parents

3. Have you ever adopted a pet from Kiya Koda?

Yes

4. Have you ever been refused adoption of a pet from Kiya Koda or any other shelter?

Yes

If yes, why?

5. Have you ever been involved with an animal control department?

Yes

If yes, what were the circumstances?

Section II — Household Details

1. How many adults live in your household?

How many children?

2. What are the children's ages (if applicable)?

Any allergies?

3. What will be this pet's role in the family? Please check all that apply.

Companion

Gift

For a child

Watchdog

Companion for another pet

Hunting dog

4. Who will be responsible for feeding this pet?

Training?

5A. Have you had any pets in the past 5 years?

Yes

5B. Are there any pets in the home now?

Yes

If so, please fill out this chart:

Breed	Age	Spayed/Neutered?	Vaccinated?	Action
				Add Delete

Breed

Age

Spayed/Neutered?

Vaccinated?

Action

Add

Delete

6. Who will be this pet's veterinarian?

7. If you move in the future, what will you do with this pet?

8. Does anyone in your household have pet allergies?

Yes

If so, what kinds?

Section IV — Certification

* By signing below, I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in the denial of my adoption application or the loss of the privilege to adopt or keep an adopted pet. I understand Kiya Koda Humane Society reserves the right to approve or deny an adoption application and may verify information provided on this application. I understand that this application is the property of Kiya Koda Humane Society.

Signature (Typed Name): *

Date:

Fields marked with * are required

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