To submit this application, print this file, complete it with the requested information, and mail or fax the completed form back to School House Rescue. Or, you can cut and paste the application into an e-mail, answer the requested questions and send it back electronically. Applications are usually reviewed within a few days of their receipt. If you don't receive a response to your submitted application within 5 school days, please call School House Rescue at the number below to inquire about its status


SCHOOL HOUSE RESCUE
Broome-Tioga BOCES ANIMAL SCIENCE
435 Glenwood Rd
Binghamton, NY 13905
Voice: 607-763-3359 / Fax: 607-763-3206
spisik@BTBOCES.ORG

Note: The term "School House Rescue" refers to the animal adoption program run by the Animal Science class at Broome-Tioga BOCES.

We know this application may seem lengthy but it really does help us evaluate whether or not the animal you are applying to adopt is a good match for your family and lifestyle. The more detail you provide, the more help we can give you in selecting a pet that you will enjoy for the rest of its life

This application must be completed by a responsible adult who is over 18 years of age.

Name:_____________________________________________________________________
Address:___________________________________________________________________
City:_____________________________________ State:___________ Zip:______________
Home Phone:_______________________________Cell Phone:_______________________
Email address_______________________________________________________________
Employer:___________________________________Work Phone:_____________________

Do you own_______rent______?  If you rent, please provide a copy of the rental agreement which allows pets and the name and phone number of landlord:
Landlord Name:_____________________________Phone Number:___________________

How long have you lived at this address?__________If less than 1 year, please provide previous address


Please list the animal(s) that you are interested in adopting:
__________________________________________________________________________
Why have you chosen this pet?_________________________________________________
__________________________________________________________________________

Describe, in your opinion, what you want this dog/cat to be..., i.e., your perfect pet:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Since we all know that no pets are perfect, what habits or characteristics are the LEAST acceptable, i.e., the behaviors that you absolutely cannot live with or will cause the pet to lose its home
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Where will the pet spend the day?______________________________________________
Where will the pet spend the night?_____________________________________________
On average, how many hours will the pet spend without human companionship?______

If you are adopting a dog:
Do you have a completely fenced yard?____  If so, how high is the fence?___________   What type of fence is it?____________________________
If your yard is not completely fenced in, how will you exercise the dog and provide adequate time for bathroom breaks? ___________________________________________________
_________________________________________________________________________

If you are adopting a cat:
Will the cat use a litter box________ or go outside________ for bathroom breaks?  If the cat will be using a litter box, where will you put the box ?    On what floor and room of the house?
_________________________________________________________________________
_________________________________________________________________________


Are you willing to let a Rescue representative visit your home by appointment?_______
Directions to house:_________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________


The following information will help us determine which pet is right for you by determining how much experience you have with the type of animal you are hoping to adopt.

Do you currently own cats?_________If yes, please list them below including name, sex, breed, age, spay/neuter, vaccination dates and description
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Do you currently own dogs ?_________If yes, please list them below including name, sex, breed, age, DOG LICENSE TAG NUMBER, spay/neuter, vaccination dates and description.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Do you currently own any other types of animals (e.g., pocket pets, farm animals, exotic pets) ?    If you do, please list them.   If they have a veterinarian other than the one listed below as a reference, please provide the name and phone number for this veterinarian.
___________________________________________________________________________

Other than the pets listed above, how many pets have you owned in the last 10 years?______
Please list all of these pets and provide the following information: Name of pet, breed, age and year of death or rehoming, veterinarian who would have spay/neuter and vaccination records.    If the veterinarian is other than the one listed below as a reference, please provide the name and phone number for this veterinarian.    If we have provided insufficient space below, attach a separate piece of paper with the information.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Note:   If your pets have received vaccinations at clinics that will not show up in regular veterinary records, please either fax or mail a copy of the certificates. This will help us determine whether you have maintained up to date vaccinations regularly.


Veterinary Reference(s):
Name:_____________________________________________________________________
Address:___________________________________________________________________
City:_____________________________________ State:___________ Zip:_____________
Phone Number:_______________________________
Please call your veterinarian and give them permission to release records to rescue. This will speed up the approval process. Also when providing veterinary information, we need ANY veterinarian that has seen your pet.

Personal References: (may not be a relative)
Personal Reference #1: Name______________________ Phone:______________________
Address:___________________________________________________________________
How long have you known this person?______ Have they ever visited your home?____

Personal Reference #2: Name______________________ Phone:______________________
Address:___________________________________________________________________
How long have you known this person?______ Have they ever visited your home?____

Personal Reference #3: Name______________________ Phone:______________________
Address:___________________________________________________________________
How long have you known this person?______ Have they ever visited your home?____


Number of adults living in your household:____Number of children living in your household:___
Age and sex of each child:___________________________________________
__________________________________________________________________________

Do you have regular visitors to your home? _____ Explain:_____________________
__________________________________________________________________________
__________________________________________________________________________

Do you understand and agree that any pet adopted from this facility must be cared for in a responsible way, which includes spay/neuter, vacinations according to veterinary guidelines and regular worming ? _____

Do you understand and agree that any pet adopted from this facility will be kept under control at all times and not allowed to run at large ? _____

Do you understand and agree that, if, for any reason, you cannot keep any animal adopted from this facility, you MUST notify this facility to allow us the option to request return of the animal ? _____

Do you understand and agree that a representative of Animal Science class may visit at any time to check on the health and well being of an animal adopted from BOCES ? _____

The BOCES Animal Science class does ask for an adoption fee in order to help cover expenses for the animals in our care. Adoption fees are payable in cash, certified check or money order only. Sorry but we cannot accept personal checks.

All of the above information which I have provided is true and complete.    Should an unneutered or unspayed dog or cat be placed with me, I agree to have it neutered or spayed by such date agreed to by me and an Animal Science representative.    At that time I will forward proof of spay/neuter to the Animal Science class.    I understand that under certain circumstances there will be a spay/neuter refund which will be discussed and arranged for at the time of adoption.

This pet will reside IN my home. I will provide it with quality food, water, shelter, training, affection and medical care.   I understand that BOCES Animal Science is a referral service and is not responsible for the accuracy of the information received about the habits, temperament or physical condition of the animal available for adoption.    I understand that it is my responsibility to evaluate the pet for myself before agreeing to adopt it.    I am in full agreement with the terms of this adoption.    BOCES shall not be liable for, and is hereby relieved from, all liability for any damage, expenses, causes or action, fines, suits, demands, judgments or claims of any nature whatsoever arising from or by reason of any damage to property or injury to any persons caused in whole or in part by the pet placed in your home.   I hereby accept and assume such liability and agree to protect, indemnify, and hold BOCES harmless from and against all of the aforesaid.    Submitting this form constitutes your permission for us to check references.

WE RESERVE THE RIGHT, IN OUR SOLE DISCRETION, TO REFUSE ANY APPLICANT FOR ANY REASON WHATSOEVER, PRIOR TO RELEASE OF OWNERSHIP OF THE ANIMAL TO ITS NEW HOME.


Thank you for contacting BOCES Animal Science class.    If, once you have completed and submitted this application, you have not heard from us within 5 working days, please do not assume that you were refused. Your application is probably still under review but feel free to contact us for the current status.

Applicant Signature: ___________________________________  Date:___________
(Applicant must be 18 years or older)

If the applicant wishes to submit this document electronically via e-mail, the applicant and BOCES both agree that the applicant's typed signature is valid and binding upon the parties.