Provisional Pet Parent Application You have been listed as a provisional pet parent to someone who has recently submitted an adoption application to The Animal League. In accordance with our adoption policy, primary care givers 75 years or older must provide a provisional pet parent who will be entrusted to care for the pet in the event of his/her passing. Adopter's Name*Who has listed you as their provisional pet parent? First Last Do you agree to be a provisional pet parent for this person?*YesNoIt dependsPlease explain your previous answer.Your Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Have you ever adopted from us before?*YesNoIf yes, who and when:Please tell us the pet's name, animal type, and date you adopted from us (e.g., "Butchie", "dog", "12/04").Your Phone Number*Your Email Address* How many adults are there currently in your home?*How many children are there currently in your home?*Please count all children under the age of 18. Count children who live in the household both full and part time.012345+If you were to become the pet parent, where would this pet be kept?* Inside Outside in kennel, fenced dog run, or fenced back yard Outside secured on chain/leash/rope (no fence) Garage Patio Crate in home Other OtherHow many other dogs and/or cats would also be living in the household?*01234 or morePets in the Household: Pet #1*Please tell us about all of the pets you currently have in your household.Name (e.g., "Whiskers")Type (e.g., dog/cat)GenderBreedAgeSpayed/Neutered?Current on vaccinations/ heartworm prevention? Pets in the Household: Pet #2*Please tell us about the second pet in your household.NameTypeGenderBreedAgeSpayed/Neutered?Current on vaccinations/ heartworm prevention? Pets in the Household: Pets #3+*Please tell us about your remaining pets in the household. Click the "+" to add more as needed.NameTypeGenderBreedAgeSpayed/Neutered?Current on vaccinations/ heartworm prevention? Primary Veterinarian*Please list your primary veterinarian here. If you currently do not have pets, please list the last vet you visited.Veterinarian's NameVeterinarian's Telephone NumberName of Veterinarian's Practice (e.g., "Clermont Animal Hospital") What else would you like to share with us?Please type your full name*This will serve as an electronic signature for this application.Date* MM DD YYYY PhoneThis field is for validation purposes and should be left unchanged.