Pet Samaritan Fund

Adoption Event

Saturday, Aug. 9
10:30 am - 5:30 pm

Saturday, Aug. 23
10:30am - 5:30 pm
See You There!

Adoption Locations
Taylorsville PetSmart,
I-215 & Redwood Road
Google® Map

This winter,
help a pet in need.

Donations go toward helping the animals and are tax deductible.

If you would like to begin adoption proceedings on a Pet Samaritan Fund pet, complete the form below. Forms submitted online take 48 hours to process. If you want to pick your pet up sooner, you will need to contact us for an appointment and fill out the paper application provided at the time of adoption. If you would like more information on a pet, contact us.

Completion of this form does not guarantee acceptance. Rates and availability may change without notice.

Adoption Fees
All rates include spay/neuter and first series of vaccinations.
	Cats	Dogs
Regular Rates	$70+	Adult dogs, $100+ Puppies, $125+
Two-Pet Special —	Ask about our special rate.
If you're a senior — or interested in adopting a senior pet — ask about our senior specials. Prices for pure breed pets may vary. NOTE: A fenced yard is required for dog adoptions. Exceptions may be made on a case-by-case basis.

Pet Desired [required]
Why did you choose this particular pet?

Personal Information
First Name
Last Name
Spouse/Partner Name
Address
City
State
ZIP
Home Phone
Email Address [required]
Driver's License
Employment Status
Where do you work?
Work Phone

Household Information
Housing Type
Is your yard fenced? [Required for dog adoptions.]	Yes	No
If renting, does your landlord allow pets?	Yes	No
Will your landlord provide written permission?	Yes	No
Landlord's Name
Landlord's Phone
Will you allow at Pet Samaritan Fund representative to visit your home?	Yes	No
Family Type
How many children are in your household?
What are their ages?
Is any member of your household allergic to:
cats?	Yes	No
dogs?	Yes	No

Pet Information
Current Cats and Dogs: Age? How long with you? Age? How long with you? Age? How long with you?
Have you ever lost a pet?	Yes	No
Had a pet hit by a car?	Yes	No
Lost a pet to disease?	Yes	No
Turned a pet into Animal Control?	Yes	No
How many hours each day would your pet be left alone?
Where would your pet be housed?
Who would care for your pet while you are on vacation?
If you move, will you take your pet with you?	Yes	No
What type of identification will your pet have?

Are you willing and able to assume the cost for the health & welfare of this pet for a probable lifetime of 10 to 15 years or more, including medical attention when needed, annual veterinary exams, and vaccinations ?	Yes	No

Will you provide proper and sufficient food, water, shelter and kind treatment for this animal at all times?	Yes	No

I CERTIFY that all the above information is correct. I UNDERSTAND and AGREE that if it should be determined that any falsifications have been made herein, or if there is any knowledge of abuse or neglect, Pet Samaritan Fund reserves the right to reclaim ownership of this pet. If I fail to return the animal on demand, Pet Samaritan Fund shall have the right without further notice, to enter the premises where the animal may be, and remove the animal without process of law. I AGREE to waive all claims for trespass or damage. As the new owner of this pet I assume all responsibility for his/her behavior. IF I CAN NO LONGER KEEP THIS PET, I will notify a Pet Samaritan Fund representative IMMEDIATELY and make arrangements to return it.
Type Legal Name
Date
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