Akita Adoption and Rescue of Mid-America
Randy Long . . . 1117 SE "W" Highway . . . .Lathrop MO. 64465
telephone (816) 740-3667 . . . .
E-mail: randog@earthlink.net
AKITA ADOPTION APPLICATION
NAME______________________________________________________________________
. . . . . . . (adopter) . . . . . . . . . . . . . . . (spouse/roommate)
ADDRESS____________________________________________________________________
CITY__________________________________STATE__________________ZIP___________
PHONE (HOME)______________________(WORK)_______________ (WORK)____________
OWN HOME___RENT___APT___HOW LONG HERE_______LANDLORD PHONE________________
PLAN TO MOVE___________WHEN________________WHERE__________________________
OCCUPATION (BOTH)_________________________________________________________
EMPLOYER & PHONE #____________________________________________________
RELATIVE & PHONE #____________________________________________________
VETERINARIAN_________________________________ PHONE ______________________
MAY WE CALL THE ABOVE REFERENCES? YES NO PREFERENCE_______________________
HOW MANY IN FAMILY ______ CHILDREN _______ AGES __________________________
CHILDREN NAMES __________________________________________________________
ARE CHILDREN DOG-TRAINED? YES NO IF NO, MAY WE TRAIN THEM? YES NO
WILL AKITA HAVE CONTACT WITH OTHER CHILDREN? YES NO HOW OFTEN____________
DO YOU HAVE OTHER PETS NOW? YES NO DOGS CATS BIRDS OTHER ________________
OTHER PET'S NAMES, SEX, AGES_____________________________________________
ARE OTHER PET'S SPAYED/NEUTERED__________________________________________
ARE THEY HEALTH_____SHOTS_____LICENSED_______SICKLY________
ARE PRESENT PETS WILLING TO SHARE HOME WITH AN AKITA? YES NO MAYBE
LIST DOGS PREVIOUSLY OWNED_____________________________________________
HOW LONG_____________WHY DID THEY LEAVE________________________________
WHY DO YOU WANT AN AKITA?_____________________________________________
WHERE DID YOU LEARN ABOUT AKITAS?______________________________________
WHAT DO YOU KNOW ABOUT THE AKITAS?_____________________________________
HOW CAN YOU PREVENT AGGRESSION TOWARD OTHER DOGS BY THE AKITA YOU WANT?
_______________________________________________________________________
CAN YOU HANDLE THE AKITA THAT BLOWS COAT TWICE A YEAR? YES NO MAYBE
WHAT CAN YOU DO TO HELP SOLVE THIS?____________________________________
HOW MUCH TIME WILL YOU SPEND WITH AKITA DAILY?_________________________
WHERE WILL AKITA STAY WHEN YOU WORK?___________________________________
WHERE WILL AKITA SLEEP AT NIGHT?_______________________________________
HOURS AKITA WILL BE ALONE DAILY: 1-2 HRS___ 2-4 HRS___ 4-8 HRS____
DO YOU HAVE FENCED YARD? YES NO HOW HIGH?_____ TYPE_________
WHEN WILL AKITA BE OUTSIDE?______________________________
WILL AKITA BE TIED ON CABLE AT ANYTIME? YES NO HOW OFTEN?________
WILL AKITA BE TAKEN FOR WALKS? YES NO HOW OFTEN?
WHO WILL WALK AKITA?___________________________________
WILL AKITA GO FOR CAR RIDES? YES NO HOW OFTEN?___________
WILL YOU BE WILLING TO OBEDIENCE TRAIN AKITA? YES NO MAYBE
WILL YOU CARE FOR THE AKITA FOR ITS LIFETIME? YES NO MAYBE
MAY A REPRESENTATIVE VISIT YOUR HOME BY APPOINTMENT? YES NO MAYBE
I understand that if for any reason the Akita cannot live with me that the Akita will be given back to AKITA ADOPTION & RESCUE OF MIDAMERICA. I will not abandon or release Akita to anyone else, no matter how good I may feel the home may be. When I contact AKITA ADOPTION & RESCUE OF MIDAMERICA, I MAY RECOMMEND someone to take the AKITA, but the final decision will be made by AKITA ADOPTION & RESCUE OF MIDAMERICA.
I will NEVER give or euthanize the AKITA. It is firmly understood that AKITA ADOPTION & RESCUE OF MIDAMERICA will forever be the guardian of the AKITA, and may check with me at any time to verify the AKITA is happy.
I agree to contact AKITA ADOPTION & RESCUE OF MIDAMERICA if the Akita has a behavioral problem, or health problem. I further agree that the AKITA will NEVER be used for any experimentation or laboratory work of any kind.
I promise I will never let AKITA run loose in the neighborhood and that the AKITA will wear tags on firm (not tight) collar at all times, with special Rescue Tag on same collar. I understand that I must license Akita yearly.
I promise that at any time, I cannot keep AKITA, and do not want to contact AKITA ADOPTION & RESCUE OF MIDAMERICA, that I will take AKITA to DR. JAMES SPARKS, DVM, EAGLE ANIMAL HOSPITAL, RIVERSIDE, MISSOURI and drop AKITA off.
I will take AKITA to my Vet. or Dr. James Sparks, DVM for a check-up within one month of adopting AKITA, to establish a medical record there. I will take AKITA to Vet. yearly for rabies shots, worm check, and basic medical check. I will not feed the AKITA "soybean" or food with "soybean" in it.
I agree to provide food, water, shelter, brushings and baths to AKITA. I will provide a clean, safe environment where AKITA will not be subject to teasing or abuse. I agree that AKITA will be a member of my family and I will care for AKITA, take responsibility and give love and attention to MY AKITA.
Before I sign below, I agree with all of the above and I will receive a copy of this application to remind me of my responsibility.
_____________________________________ ____________________________________
_____________________________________ ____________________________________
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Date approved _____________ Housecheck date _____________ Fee ___________
Date AKITA moved ___________ Initial ______ AKITA'S NAME _________________