Type of Pet Desired: Lizard Snake Frog Turtle Other

What is the reason for adopting this pet? Companion for other pet For the children Gift Companionship Breeding Classroom Use Other

First Name: Last Name: Cell #

Street:

Apt #:

City:

State: Zip:

Type of Housing: Rent apartment Rent House Own House Other

If you rent, what is your landlord's name?: Phone #:

Number of adults in household: Number of children in household:

Children's ages:

Does anyone have allergies to animals? If yes, what kind of animal allergy?

Who is your veterinarian? City Phone #:

Please list reptiles/amphibians presently in your household. Species Sex Age How long owned Where Kept

Please list reptiles/amphibians owned previously in the last 5 years. Species Sex Age How long owned What happened to pet?

Have you ever owned the kind of pet you wish to adopt? If yes, how long ago?

What happened to the pet?

Did the pet ever have offspring? If yes, what did you do with the offspring?

How will you house your pet? Loose in the yard? Loose in the house Cage (Size dimensions High Wide_ Deep )

Where will your pet be kept? Outside In Garage Covered outside area In house

Who will be responsible for your pet's care?

Are you familiar with this pet's needs for: Food/water Heating/Lighting Vet Care

©2014 Reptile Rescue Orange County. Page 1 of 2

If this pet is intended for classroom use, please answer the following:

Name of your school: Phone #:

Address:

Age/Grade of children Number of hours the school is open each day Number of children

Number of adults Who will be the main guardian (responsible person) of this pet?

What care arrangements have been made for the pet durring:

Weekends?

Extended holidays?

What will happen to the pet at the end of the school year?

What kind of experience do you have with this type of pet?

Is this pet going to be part of a teaching unit you are planning? If yes, how so?

What is your main purpose in adopting this pet?

What will happen to this pet is his/her temperament is not suitable to a classroom setting?

Signature Date

Home Check Notes:

Enclosure details:

Notes:

Pending Impound Check Approved Denyed Date:

By:

©2014 Reptile Rescue Orange County. Page 2 of 2