On this date __________________ Safe Haven Animal Rescue is transferring ownership of _________________________________ to

____________________________________________________________.

The adoption donation for this pet is __________. This covers medical

costs and assorted supplies/medications as needed. Safe Haven is a non-profit rescue. A fully volunteer organization without funding except for adoption donations.

Name: ____________________ Age: __________ approx/accurate (circle one)

Sex: _______ Color:__________________ Breed: __________________________

Spaying or neutering has been completed prior to adoption.

Exceptions: The animal is not yet old enough or the animals health does not permit spaying/neutering.

All pets who’s health permits, must be spayed/neutered by 6 months of age. Proof must be provided within 10 days of operation or the pet can be reclaimed immediately.

Safe Haven obtained this dog from a shelter or owner under conditions that information on age, breed, prior training are sometimes unknown and untraceable. Safe Haven makes no warrantees of any kind - this includes health and temperament guarantees. The adopter hereby releases and forever discharges Safe Haven and its representatives from any actions, cause of actions, suits, liabilities, claims, demands, damages or causes of any kind. Whether presently existing or arising in the future. The adopter is to be solely responsible for this animal and any damages that may result from its actions. The adopter is responsible for the costs of any medical conditions that may arrise in the future.

Last vet exam: __________ @ ___________________________________________

DHLPP: __________ Rabies: __________ HW/Lyme Test: __________

Spayed/Neutered: __________ Micro chipped: __________

Worming: __________ Flea & Tick Preventative Given: __________

HW Preventative Given: __________

Other medical information: ________________________________________________________________________________________________________________________________________________

Know behavior challenges that adopter acknowledges and may need to address: ______________________________________________________________

________________________________________________________________________

You must notify Safe Haven IMMEDIATELY if the animal is lost or stolen.

If for any reason the adoption is not satisfactory or if health/life changes make it necessary to give up the animal it must be returned to Safe Haven. It cannot be transferred to any other person or organization for any reason.

You must notify Safe Haven of changes in address or phone number.

The animal will reside indoors as a family member and cannot be outdoors without proper supervision.

You agree to abide by all state and local animal control and leash laws. It is your responsibility to become familiar with these laws.

The animal must receive proper veterinary care. Including yearly check-ups and the use of preventatives. Adequate food and water must be supplied on a regular basis.

The animal cannot be crated for more than 8 hours a day.

The animal must wear rabies tag, license (where necessary) and identification at all times.

I have read & understand my obligations and agree to them: ________ (Initials)

Safe Haven reserves the right to follow - up on this adoption in order to protect the welfare of the animal. If any statements made by adopter prove false or the adopter does not uphold the terms and conditions of this contract Safe Haven reserves the right to reclaim the animal.

Should it become necessary to take action to recover the adopted animal the adopter will be responsible for all cost incurred to retreive said pet.

Including but not limited to: lawyer and court costs.

Adopters signature: ____________________________________________________

Address:_______________________________________________________________________________________________________________________________________

Home Phone: ____________________ Work Phone: ______________________

Drivers License Number: _____________________________ State: _________

Rescue Representative: ________________________________________________

Date: _____________________

Safe Haven Animal Rescue

HC 1 Box 1654

Blakeslee, PA 18610

570-646-4652