CONTRACT WORKING DOG ( CWD ) ADOPTION APPLICATION

Transcription

1 CONTRACT WORKING DOG ( CWD ) ADOPTION APPLICATION Thank you for considering the adoption of a CWD. Take a few moments to carefully read and complete this application. The decision to adopt a CWD is one that must be taken seriously. In order to ensure that you and the CWD will be happy and safe for years to come, we need to take time to discuss your expectations and the CWD s individual needs. Please answer all the questions as thoroughly as possible. PERSONAL DATA Name (Last Name, First, MI): Spouse (Last Name, First, MI): Home Address: Apt: City: State: Zip Code: Home Phone: Are You: Working Retired Attending School Homemaker Other Employer s Name: Work/Cell Phone.: Spouse Employer s Name: Spouse Work/Cell Phone.: Employer s Address: Work Hours: Spouse Employer s Address: Spouse Work Hours: Address: HOUSEHOLD INFORMATION Are there any other adults living in your household? If yes, please list the other adult household members below: 1. Name: Employer s Name: Work/Cell Phone.: Work Hours: 2. Name: Employer s Name: Work/Cell Phone.: Work Hours: Maximum number of hours CWD will be left alone daily? Who will be the primary caretaker of the CWD? Self Spouse Children Roommate How many children are living in the household? Please list ages of children living in the household: Do you: Does your landlord/lease allow pets? Do you have screens on your windows? Own Rent Where will the CWD be kept primarily? Do you have a fenced-in yard? Inside Outside If yes, how high is the fence? Are any members of your household allergic to pets? PET INFORMATION Please list any animals you have owned in the past five (5) years below: Page 1 of 6

2 Type of pet Age Spayed/Neutered? Years owned? Do you still have this animal? If not, where is it? Are your animals vaccinated yearly? Do you give monthly Heartworm Preventative? Do you give monthly Flea/Tick Preventative? Veterinarian s Name: Veterinarian s Address: Veterinarian s Phone.: PHONE REFERENCES (People not living with you who can be reached by telephone who know your history and treatment of animals. You may also submit letters of reference.) 1. Reference s Name: Reference s Address: Reference s Phone.: 2. Reference s Name: Reference s Address: Reference s Phone.: CWD s Name: CWD s Breed: CWD s Age: CWD s Sex: Why are you interested in giving a home to this CWD? *Please note: Each CWD is identified with a microchip number, branding and other forms of physical identification are not utilized Have you ever owned a dominant dog? If yes, please answer the following: What were the breed(s)? How long did you have the dog(s)? Where is/are the dog(s) now? Do you intend to use this CWD for personal protection or commercial property security? If yes, please explain: Did the dog(s) you owned in the past ever bite or show aggressive behavior towards you, your family members, or any other individuals? If yes, please explain: Have you ever trained a dog before? Page 2 of 6

3 If yes, please answer the following: What type of training methods did you use? What type of discipline/corrections would you use with the CWD? If the CWD needs professional training, are you willing and financially able to enroll the CWD in a group class or with a private trainer? Have you applied to adopt a Military Working Dog or CWD before? If yes, from where? How did you hear about our adoption website? Newspaper Internet Friend TV Other: Is someone in your home nervous or unsure of dogs and to what degree? Very Moderately Some (no experience with dogs) t Applicable Do you have any of the following (check all that apply): Indoor Cat(s) Indoor/Outdoor Cat(s) Dog(s) Other pets (please list): The noise/activity level in your home is usually: Low Medium High When it comes to keeping a clean and tidy house you are: Very particular Particular Easygoing When it comes to pets lying/sleeping on the bed or furniture you would: Allow t allow t care How often would you brush or groom the CWD? Rarely Occasionally Daily Weekly Monthly How often would you take the CWD in your vehicle with you? Daily Weekly Frequently Once in a while Other: You would prefer a CWD that can tolerate being alone for: hours per day You would prefer a CWD whose energy level is: Low Medium High You would prefer a CWD that (check all that apply): Will enjoy walking with you on a leash Will enjoy walking with you off a leash Will run, jog or hike with you Will exercise him or herself in the yard Requires little exercise Enjoys playing fetch Do you have or are you planning to have (check all that apply): A fenced yard A dog run A stationary tie-out Page 3 of 6

4 Please describe your ideal CWD: Please tell us anything else you would like us to know about you and why you are interested in adopting a CWD: I agree to accept full liability for all actions of the CWD. RECIPIENT S ACKNOWLEDGEMENTS I agree to provide reasonable indoor climate controlled shelter for the CWD. I agree to obtain and provide proper medical care for the CWD (i.e. vaccinations, yearly health exams, external and internal parasite control, dental cleaning, etc.). I acknowledge that I am adopting a retired CWD that may be of advanced age, have decreased workability, or have various health problems. I acknowledge I have been informed of the known health concerns of the CWD and agree to notify veterinary staff that this dog is a former CWD. I agree to provide adequate food and water and necessary supplements for the CWD. I agree and acknowledge that I have been fully briefed and have knowledge on the training received by the CWD. I agree to notify groomers or others tending to the dog that he or she is a former CWD. I agree to abide by all local animal control, dangerous animals, and licensing laws with respect to the CWD. I agree that I have been briefed on the list of critical commands used to control the CWD s behavior. I agree and acknowledge that I have received a written summary of the CWD s shot records. I agree to notify Piper s Rescue at sara@pipersplayhouse.org in the event I need to relinquish the CWD. I will give a Piper s Rescue representative a minimum of ninety (90) days, after providing notice of my need to relinquish the CWD, retrieve the CWD from me. I agree to notify Piper s Rescue at sara@pipersplayhouse.org in the event I need to rehome the CWD. I will give a Piper s Rescue representative a minimum of ninety (90) days, after providing notice of my need to rehome the CWD. Piper s Rescue reserves the right to approve or disapprove the CWD s new home. If Piper s Rescue disapproves of the CWD s new home, Piper s Rescue reserves the right, in its sole discretion, to rehome the CWD in a home of its choosing. Page 4 of 6

5 CONVENANT NOT TO SUE AND INDEMNITY AGREEMENT THIS COVENANT NOT TO SUE AND INDEMNITY AGREEMENT: that American K-9 Detection Services, LLC, a Delaware Limited Liability Company and its affiliates, subsidiaries, and parent companies, with principal offices at 1791 O.G. Skinner Drive, Suite A, West Point, Georgia, (hereinafter referred to as AMK9 ) has delivered through by means of transfer and/or with the help of Piper s Rescue, a non-profit corporation, corporation duly organized, validly existing and in good standing under the laws of the State of Alabama, with its principal office and place of business at 1221 ble Street, Anniston, Alabama, ( Piper s Rescue ) to, (hereinafter referred to as "Recipient"), the following contract working dog (hereinafter referred to as "CWD ): NAME BREED WHELP DATE / AGE SEX MICROCHIP NUMBER In consideration of the transfer of legal ownership of the above-referenced CWD to Recipient, the receipt and sufficiency of which is hereby acknowledged, Recipient does hereby covenant and agree that neither it, its heir(s), agents(s), assign(s), executor(s), successor(s), or administrator(s), will commence, institute, or maintain, or in any way aid in the commencement or institution of any suit, action at law, or claim against AMK9 or Piper s Rescue, or any employee(s), agent(s), or servant(s) thereof, for, or by reason of, any damage, loss, or injury, either to person or property, or both, or wrongful death, caused directly or indirectly by the CWD. In further consideration of the transfer of legal ownership of said CWD to Recipient, Recipient hereby agrees to indemnify and hold harmless, both at law and in equity, AMK9 or Piper s Rescue, and all agent(s), servant(s), or employee(s) thereof, against any and all claims for injury, damages, compensation or otherwise, which may arise at any time, and which may be attributable, directly or indirectly, to the CWD, or to any training of the CWD by AMK9 or Piper s Rescue, its agents, servants, or employees, and to reimburse AMK9 or Piper s Rescue, and all agent(s), servant(s) or employee(s) thereof, for any and all expenses, including any and all losses, damages, claims, expenses, and attorneys' fees incurred as a result of any claim(s) made by Recipient, its heir(s), agent(s), assign(s), executor(s), successor(s), or administrator(s), or by any other party who may institute any type of claim with respect to the CWD against AMK9 or Piper s Rescue, or any agent(s), servant(s) or employee(s) thereof. AMK9 or Piper s Rescue, and all agent(s), servant(s) or employee(s) thereof, shall not be liable for any veterinary expense or treatment of any kind associated with the transfer of the CWD, or for any hereditary or medical condition of the CWD, whether or not such condition is known at time of transfer. As a condition of transfer, Recipient further warrants that the CWD will not be used for any illegal purpose, for police, military, paramilitary, or security related activities, private business activities, or substance and explosive detection activities (whether in the public or private sector). Furthermore, Recipient shall not give, sell, or otherwise transfer the CWD to another person and agrees that in the event it cannot take care of the CWD, it shall provide notice to AMK9 or Piper s Rescue, who will attempt to find a new home for the CWD. Recipient specifically acknowledges that the above mentioned CWD may have received aggressive (patrol) training and having such knowledge, said Recipient, as a condition of the transfer of legal ownership of the CWD to the Recipient, freely and voluntarily accepts all risks and consequences of the future conduct and acts of the CWD. Page 5 of 6

6 This Agreement shall be governed by the laws of the United States of America and the State of Georgia. The exclusive jurisdiction and venue for any action arising out of this Covenant t to Sue and Indemnity Agreement shall lie exclusively in the United States Federal Courts in the rthern District of Georgia or, when appropriate, in the state Circuit Court in, and for, Troup County, Georgia. Recipient s Signature: Date: Recipient s Name (Please Print): Recipient s Address (Street, City, State, Zip Code): Recipient s Telephone.: NOTARY SECTION: STATE OF: COUNTY OF: I hereby certify that on this day of 201, the foregoing instrument was signed before me, an officer duly authorized to take acknowledgments in the aforesaid State and the aforesaid County, by, who is personally known to me or who provided as identification., NOTARY PUBLIC My Commission expires on: AMERICAN K-9 DETECTION SERVICES, LLC By: Date: Name and Title (Please Print or Type): PIPER S RESCUE By: Date: Name and Title (Please Print or Type): Page 6 of 6