MID-CITIES HUMANE SOCIETY

I.D. Tag #

Rabies Tag #

Control #

Pet’s Name:

Cat Dog

Breed

Gender:

M F

Age

Color/Desc.

Veterinarian:

Vet Phone #

PET ADOPTION CONTRACT

Thank you for your interest in adoption. Before completing the application, please read through our Adoption

Terms/Conditions. All potential adopters are screened for appropriate placement of animals and Mid-Cities Human

Society reserves the right to deny any application.

Name

Home phone #

Address

City

State

Zip

House Apt Other

Fenced Yard? Yes No

Driver’s License #

Employer

DOB:

Work phone

Cell Phone

Name of Veterinarian clinic:

City/State:

Phone Number:

Name(s) of pets this vet has seen:

STERILIZATION AGREEMENT

I understand that I am required by state statue to have this adopted animal sterilized by:

LIQUIDATION DAMAGES, DISCLOSURE & RELEASE CLAUSE

(Read detail and initial page 3)

The adopter has read, understands and agrees to the terms and conditions set forth on page 2 agreement.


Adopter’s Signature		Date

MCHS Witness		Date

Mid-cities Humane Society USE ONLY

Payment information:	Basic Adoption Fee	$
Cash	Additional Charges	$
Check #	Donation	$
	Total Paid	$

MID-CITIES HUMANE SOCIETY

P.O. BOX 540493

GRAND PRAIRE, TX 75054-0493

972-263-4567

ADOPTION AGREEMENT

By signing this form, I agree to the following terms and conditions.

I agree to provide the animal with necessary veterinary care upon sickness, disease, or injury and

shall take him/her to the veterinarian at least once a year for an annual health examination and

routine vaccinations.

I agree to provide adequate food, water, and shelter to the adopted pet and ensure that he/she is

treated in a humane manner at all times.

I agree to notify MCHS of any changes of address or phone number. If the pet becomes lost or

stolen, I agree to notify MCHS immediately, within 24 hours.

If I should decide, for whatever reason, that I cannot continue keeping the pet, I will notify

MCHS immediately. I will NOT turn the pet over to an animal shelter, have it destroyed or

release the pet to any other persons or abandon it.

I agree to provide a collar identification & rabies tag for the animal to wear at all times when

allowed outside. Dogs that are tagged have a greater chance of getting returned to their owners.

I attest that I am NOT obtaining this animal for use in any type of experimentation, for the sale

to any agency that performs experiments on animals or dog fighting.

As far as is known by MCHS each animal is reasonably sound. MCHS does not necessarily

know the nature of the animal or characteristics, and gives no warranties, expressed or implied,

of temperament, fitness, or merchantability.

I understand that MCHS may examine and make inquires about the pet at any time. If the

condition of the adopted pet in which it is kept is not satisfactory, or if there is evidence that any

other provisions of this contract are being violated, the dog/cat may or will be removed

immediately. Any necessary veterinary services due to negligence or lack of care will be the

adopter’s financial responsibility.

I agree to take every necessary precaution to ensure that any unaltered animal in my care

does not reproduce. I agree that, should I adopt an unaltered animal, it will be altered (rendered

sterile) within 30 days of the adoption. In the event the animal is not of age for sterilization, I

agree to have the animal altered (rendered sterile) within 30 days of reaching eligible age. My

failure to comply with this without showing justification otherwise constitutes just cause for

Mid-Cities Humane Society to revoke the adoption, and to remove said animal from my

ownership and care. The adoption fee is non-refundable.

Acknowledgement initials

STERILIZATION AGREEMENT

I understand that STERILIZATION OF THE ANIMAL IS REQUIRED UNDER

CHAPTER 828, HEALTH AND SAFETY CODE, and that A VIOLATIO OF THIS

CHAPTER IS A CRIMINAL OFFENSE PUNISHABLE AS A CLASS C

MISDEMEANOR.

I further understand that I must present to the Mid-Cities Humane Society proof of sterilization

by the veterinarian who performed the surgery. The letter must contain a statement that the

animal has been sterilized, the date of that sterilization, a brief description of the animal and

reference the Mid-Cities Humane Society’s control number for that adoption. The letter must be

presented in person or by mail within seven (7) days of the sterilization date.

LIQUIDATED DAMAGES CLAUSE

Liquidated Damages: Adopter agrees to pay the Mid-Cities Humane Society the sum of

$150.00 as liquidated damages in the event the terms of this contract are breached; this liquidated

damage value is agreed to for the purpose of establishing value of the animal and does not bar

the Mid-Cities Humane Society from seeking return of the animal by a judicial process or other

legal means.

Attorney’s Fees and Court Cost: Adopter agrees to pay reasonable attorney’s fees and court

costs in the event this matter is forwarded to an attorney for enforcement.

DISCLOSURE AND RELEASE CLAUSE

I do hereby declare that I am aware:

That animals are different from human beings in their responses to human actions;
That the actions of animals are often unpredictable;
That animals should be closely supervised when they are with children;
That an animal’s behavior may change after it leaves the shelter and accustoms itself to

a home or other different environment; and

That the Mid-Cities Humane Society makes no claims or representations as to the temperament,

health or mental disposition of any animal put up for adoption.

I hereby accept possession of, title (subject to conditions in the adoption contract), and

responsibility for the animal identified above and hereby release and discharge the Mid-Cities

Humane Society forever from liability for any injury or damages to any persons or property

cause in the future by said animal, and from any causes of action, claims, suites, or demands

whatsoever that may arise as a result of such injury or damages.

Acknowledgement initials