Horse Adoption Application

(Staff use) ID # ________________    ARK checked ____/____/________

In order to be considered for an adoption you must:   1) be 21 years of age   2) have the knowledge and consent of all adults living in your household   3) have a valid ID with current address   4) understand that completing this application does not guarantee adoption and that the Humane Society of Central Illinois must approve your application.

Name __________________________________________________________________________________   Date ____/____/________

(Please print name)

Name of spouse/parent/legal guardian: _______________________________________________________________________________

(Please print name)

Address: _______________________________________________________________________________________________________ City: ______________________________________________________   State: __________________   Zip Code: _________________ Home phone: _________________________   Work phone: _________________________   Cell phone: _________________________ Employer: ____________________________________________________________________________________________________ Name/description of the horse(s) you want to adopt: ____________________________________________________________________ ____________________________________________________________________________________________________________ Where will the horse(s) be housed?   _____ On my property   _____ At a boarding facility   ___ Other (describe) _____________________ ____________________________________________________________________________________________________________ Please provide directions to your property/other property where horse(s) will be housed: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ If using a boarding facility, provide the facility's name and address: _______________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Contact person at facility and phone number: ________________________________________________________________________ ____________________________________________________________________________________________________________ Veterinarian's name: ___________________________________________________________________________________________ Veterinarian's address: _________________________________________________________________________________________ ____________________________________________________________________________________________________________ Veterinarian's phone number: ____________________________________________________________________________________ Farrier's name: ________________________________________________________________________________________________ Farrier's address: _______________________________________________________________________________________________ ____________________________________________________________________________________________________________ Farrier's phone number: ________________________________________________________________________________________ Describe the type of shelter provided for the animal: __________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Describe the type of fencing used: ________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Describe the type of feed and feeding schedule you will use: ____________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ How many horses do you currently own? ____________________________________________________________________________ What experience do you have with horses? ________________________________________________________________________--_ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ How do you plan to use the adopted horse(s), if you are approved? ________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Who will be the primary rider/caregiver of the animal and what is his/her experience with horses (if different from the person completing this application)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ If you belong to any horse organizations, please list them: ______________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Please initial:

________	I authorize the Humane Society of Central Illinois to check any and all references they deem necessary to determine if I am eligible to adopt an animal.
________	I agree to strictly adhere to the Humane Society of Central Illinois's policy of gelding all male animals, including any possible offspring of adopted animals.
________	I agree that the intent when adopting from the Humane Society of Central Illinois is to provide a responsible, loving home for the animal(s) for the rest of its/their life/lives. I understand that this may be a 20 year or longer commitment. If for any reason I can no longer care for this animal/these animals, I will contact the Humane Society of Central Illinois for assistance in finding a new owner or placement in a foster home, or return the horse to the Humane Society of Central Illinois.
________	I understand that the Humane Society of Central Illinois reserves the right to make unannounced inspections during the first year and announced inspections during the first three years after adoption to ensure the animal(s) is (are) receiving adequate care.
________	The Humane Society of Central Illinois makes no representations as to the health or disposition of the animal(s) adopted. The Humane Society of Central Illinois reserves the right to place the animal(s) in the home that it deems most appropriate for each animal.

By signing below, I certify that the information given is true and correct and I recognize that any misrepresentation of facts will result in my losing the privilege of adopting a pet. I also give my veterinarian permission to release any vet care records and information about my current and past pets to the Humane Society of Central Illinois. I understand that this application is the property of the Humane Society of Central Illinois and that the Humane Society of Central Illinois has the right to deny my request to adopt.

Signed X ____________________________________________________   Date _____/_____/_________                 Applicant Signed X ____________________________________________________   Date _____/_____/_________                 Circle one: Spouse / Parent / Guardian

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