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Adoption Application

1Applicant

2Family

3Home

4Care

5Preferences

Hidden
Default: Adopter Status
First Name*
Last Name*
Age Range*
eMail Address*
eMail Address Confirm eMail Address
Street Address*
Suite | Apt or Unit Number
City*
State/Province*
Postal Code*
Country
Home Phone Number
Work Phone Number
Cell Phone Number*
- Preferred Method of Contact*
Employment & Schooling
- Are You Employed?*
  - Yes
  - No
  - Retired
- Full or Part Time?*
- Are You in School?*
  - Yes
  - No
- Full or Part Time?*
- How Did You Hear About Us?*
- What Is Your Friend's Name?
- Which Shelter?
- Which Rescue?
- Please Describe

Below are three areas for information on other members of your family. Please include all other adults, children and pets living in your home by clicking on the designated button.
Adults
Are There Other Adults In The Home?
- Yes
- No
How Many?*
Adult 1
Relationship To Applicant*
Please Describe*
Adult 2
Relationship To Applicant*
Please Describe*
Adult 3
Relationship To Applicant*
Please Describe*
Adult 4
Relationship To Applicant*
Please Describe*
Children
Are There Children In The Home?*
- Yes
- No
How Many?*
Child 1
Previous Experience with Reptiles*
Child 2
Previous Experience with Reptiles*
Child 3
Previous Experience with Reptiles*
Child 4
Previous Experience with Reptiles*
Reptiles
Do You Now or Have You Ever Had a Reptiles?*
- Yes
- No
Please list what species you have and how many:*
Other Pets
Are There Other Pets In The Home?*
- Yes
- No
Please list what types of pets you have and how many:*

Residence
- Type of Residence*
- Please Describe Type of Residence
- Do You Own or Rent?*
- Does Landlord Allow Reptiles?*
  - Yes
  - No
- Are There Any Breed Or Size Restrictions?*
- Please Provide Landlord's Name*
- Please Provide Landlord's Phone Number*
Yard Information
Do You Have A Yard?
- Yes
- No
Is The Yard Fenced?
- Yes
- No
How High Is The Fence?
What Is The Lowest Point of The Fence?
What Material Is The Fence Made From?
Please Describe Fence Material
Is The Lawn Treated?
- Yes
- No
Do You Have A Pool?
- Yes
- No
Is The Pool Completely Fenced?
- Yes
- No

Family & History
- What Type Of Household Do You Have?*
- Please Describe*
- Do All Family Members Want A Reptile?*
  - Yes
  - No
- Please Explain Who Doesn't and Why They Don't*
Are You WIlling To Take Responsibility For This Reptile For The Next 10-25 Years or more?*
- Yes
- No
What Provisions Will You Make For The Reptile Should You Become Unable To Care For Him/Her?*
- Are You Capable of Providing Timely Healthcare?*
  - Yes
  - No
- What Are You Willing/Able To Spend On Vet Care?*
- Please Explain Your Circumstances*
Feeding
- Who Will Be Responsible For Feeding The Reptile?*
Enclosure Setup
- Where Will The Enclosure Be Set Up?
- Who Will Care For The Reptile While You Are On Vacation?*
- Please Explain Who Will Care For The Reptile*
If you have your own reptile habitat already, we ask for a picture of your setup for approval. Please email pictures to adoptions@littleresq.net.
Personal Reference
Please Provide A Personal Reference
Please Provide Reference's First Name*
Please Provide Reference's Last Name*
Please Provide Reference's Phone Number*
Please Provide Reference's eMail Address*
Relationship to Applicant*
Years Acquainted*
Veterinarian Information
Have You Used A Veterinarian Before?*
- Yes
- No
Please Provide Veterinarian's Name*
Please Provide Veterinarian's Phone Number*
Boarding Facility Information
Have You Used A Boarding Facility Before?
- Yes
- No
Please Provide Boarding Facility's Name
Please Provide Boarding Facility's Phone Number

Reason For Adoption
Select all that apply.
Family Companion*
- Yes
- No
For Child*
- Yes
- No
Gift*
- Yes
- No
Companion For Current Reptile*
- Yes
- No
Replace A Previous Reptile*
- Yes
- No
- Other*
  - Yes
  - No
- Please Describe Reason For Adoption*
Would You Consider:
Fostering While Waiting For The Perfect Reptile?*
Two Or More Reptiles?*
A Reptile The Needs To Be Alone?*
A Reptile That Needs Medications?*
A Reptile That Has A Serious Health Condition?*
A Reptile That Has Special Needs?*
- Select Gender*
- Select Age Range*
- Select Personality*
  Select All That Apply
- Select Color of Reptile
- Do You Have A Preferred Reptile?*
- List Other Reptiles You Are Interested In
- When Will You Be Ready To Adopt?*
Is There Anything Else You Would Like to Let Us Know?
I am interested in receiving pet related services and products*
- Yes
- No
Authorization
Authorization:*
I understand that I release Little RES Q of any liability in regards to the health or behavior of the reptile being adopted. While it is understood that every effort has been made to provide an accurate assessment of the history and health of the animal, Little RES Q explicitly disclaims warranties regarding medical status or behavior of said reptile. As the adopter, I agree not to hold Little RES Q liable for any claims of injury to property or persons or otherwise caused by the reptile. I understand that all information on my Preliminary Rescue Adoption Application will be kept confidential; my information will not be disclosed to any third parties; and that my application will be kept on file until I notify Little RES Q that I am no longer interested in a rescue. I understand and agree *
- I agree
Comments
This field is for validation purposes and should be left unchanged.

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