Petstablished | Manage your Animal Welfare Organization (AWO) with our easy-to-use software.

You can save your current form progress and come back later.

Save Progress

Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

* GenderMaleFemale

Country

*State/Province

Date of Birth

* Month

* Day

* Year

More Information

Driver's License Number:

Name of Animal:

Agreement

Acknowledgements: I acknowledge receiving custody of the animal described below and agree to the following: I will provide humane care, giving the animal proper food, water, shelter, and love. I will provide immediate, competent veterinary care in case of illness or injury. I will not attempt to hold PCHS, the delivering individual, or sponsoring organization responsible for any damages which the animal may do to any person or property.

Yes

Agreement. PCHS and the sponsoring organization are not responsible for any obligations, medical or otherwise, and make no claims or representations regarding the behavior, health, or temperament of animals put up for adoption. I also agree to return said animal to PCHS if for any reason I am unable to provide proper care for or keep said animal. I understand that home visits could be conducted at any time. If the terms of the agreement are not met, PCHS reserves the right to reclaim the animal.

Yes

Liquidated Damages Clause. I will not give or sell said animal to anyone without permission from PCHS. If for any reason I cannot continue to care for said animal, I will first attempt to return it to PCHS. Liquidated Damages: Adopter agrees to pay to PCHS the sum of $150.00 as liquidated damages in the event that the terms of this contract are breached; this liquidated damage value is agreed to for the purpose of establishing the value of the animal and does not bar PCHS for seeking a return of the animal by a judicial process or other legal means. Attorney’s Fees and Court Costs: Adopter agrees to pay reasonable attorney’s fees and court costs in the event this matter is forwarded to an attorney for enforcement.

Yes

Spay/ Neuter Agreement. If the pet I am adopting has not yet been surgically sterilized, I agree to bring the pet back to Polk County Humane Society on the date PCHS and I agree upon, for a spay/ neuter procedure. I understand that the spay/ neuter procedure is necessary to preserve my pet's health and wellness, and help reduce the homeless pet overpopulation. I understand and agree that if I do not bring my pet back for the scheduled appointment, PCHS will reclaim ownership of the pet, including coming to my home to repossess the pet with law enforcement, if necessary. If I miss my appointment and PCHS is unable to reach me, I will be held financially responsible for all attempts to contact and reclaim the pet in my possession, including any publishing, postage and/ or attorney fees.

If PCHS permits me to take my adopted pet to a different veterinarian for surgical sterilization, I agree to provide PCHS with record of the spay/ neuter surgery within 1 (one) week of the procedure completion.

Yes

Signature / Date:

In accordance with the above contract, it is my understanding that PCHS may examine and inquire about the animal at any time, and if not satisfied with conditions, said animal shall be returned to PCHS. I have thoroughly read and agree to all of the above requirements. TYPE YOUR NAME AND THE DATE BELOW.