​​By submitting this application, I agree that:

 1.  I am authorizing, through submission of this form, the Veterinarian named above to release any information and records concerning past or present care of animals to A Second Chance Animal Shelter. I agree to hold harmless and indemnify said Veterinarian for providing such information.

 2.  I have not, nor has anyone in my household, ever been charged with any form of animal abuse, neglect or cruelty.

 3.  This animal will be cared for and treated with love and respect. I agree to be fully responsible for it’s well being including the following:   

Providing veterinary treatment for continued health, adequate and wholesome food, fresh water, and shelter from the weather.
If I can not provide for the animal any longer, I will contact A Second Chance Animal Shelter and make arrangements to return the animal to them, with NO refund of fees. I certify all statements made by me on this agreement are true and correct. I agree that ASCAS has the right to refuse adoption or confiscate the above described animal in the event that any statement made by me is found to be false and/or the check for the adoption is returned for insufficient funds.