Adoption Application - Cape Coral Animal Shelter

Name

This field is for validation purposes and should be left unchanged.

Name of animal you wish to adopt:

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone(Required)

Home Phone

Work Phone

Email Address(Required)

Home Information:(Required)

Own House

Own Condo

Rent a House

Rent Condo/Apartment

Government Assistance/College Housing

(Select One)

Do you have an HOA?(Required)

Yes

Are there restrictions?(Required)

Yes

If you rent what is the name and phone number of your Landlord, Condo/Homeowner’s Association, Property Manager/Agent?(Required)

How long have you lived at current address?(Required)

Are you planning on moving within the next six (6) months?(Required)

Yes

If you move, what will you do with your pets?(Required)

Do you have access to a yard/lanai?(Required)

Yes

The yard is:(Required)

Open

Fenced

Enclosed Lanai

Height of fence:(Required)

What are your reasons for wanting a pet?(Required)

Who will be responsible for the care of the pet?(Required)

Length of time during the day pet will be left alone.(Required)

Where will pet be kept during day?(Required)

Night?(Required)

Have you ever adopted from this shelter before?(Required)

Yes

When?(Required)

Have you ever brought an animal to an animal shelter under any circumstances?(Required)

Yes

What was the reason?(Required)

Do you object to the Cape Coral Animal Shelter inspecting your premises?(Required)

Yes

INCLUDING YOURSELF, please list the NAMES and AGES of all members of your household:(Required)

Name

Age

Do you have a plan for the long-term care of your pet in the case of your death or permanent disability?(Required)

Yes

If yes, please list name and phone number for person that will be responsible for the care of your pet:

Name

Phone Number

Please list all animals you have owned from the past FIVE years, including those that have passed away. Be sure to include ALL animals currently living in your home, even if they are not your personal pets (for example, a roommate's or family member's pet). Also include small caged pets (hamsters, rabbits, birds, etc.) and barnyard animals

Pet History

Name

Breed or type

Age

Sex

Spayed or neutered? (yes or no)

Kept where? (in or out)

If no longer in your home, what happened to pet?

Name of your Veterinarian or Veterinary Hospital(Required)

Upload Vaccine Records

Max. file size: 15 MB.

Is there anything you would like to discuss with the adoption counselor?

Please initial below statements:

I certify that I am 21 years of age or over.(Required)

Please initial in box.

I understand veterinary and nutritional care may cost over $2,000 annually and accept this financial responsibility.(Required)

Please initial in box.

I understand a pet can live 10-18 years and I will be responsible to ensure my pets are cared for upon my death or permanent disability.(Required)

Please initial in box.

I understand that CCAS reserves the right to refuse any application for any reason.(Required)

Please initial in box.

I certify that all the information on this application is true and any false information may void this application.(Required)

Please initial in box.

For and in consideration of my visit to the Cape Coral Animal Shelter, I, hereby, on behalf of myself, any minors accompanying me, my successors, heirs, executors and assigns, do hereby fully release and forever discharge, waive, release, and hold harmless the Cape Coral Animal Shelter, and its officers, directors, agents, attorneys, employees, successors, assigns and affiliates, from any and all injuries, illnesses, damages, liability, actions, causes of action, attorney’s fees, costs, expenses, suits, claims and demands, or any other actions or causes of action of whatsoever kind and nature, direct or indirect, in law or in equity, whether known or unknown, suspected or unsuspected, past, present, or future, which I, my successors, heirs, executors and assigns, now have, have had, or may at any time hereafter have by reason of, related to, with respect to, or in any way arising or resulting from the presence or the activities undertaken therein.

I understand that I am assuming the risk for all damages to my person or property which I may sustain while visiting CCAS. Furthermore, I acknowledge that the Cape Coral Animal Shelter will not be responsible for any liability arising from any actions or claims relating to or associated with this visit or any damages, injuries, or illness that I may suffer or sustain therefrom.

Signature:(Required)

Date:(Required)

Signature:

Date:

Adoption Information & Hours | 239-573-2002

Bringing new hope to homeless animals

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