Adoption Application Step 1 of 333%The undersigned hereby makes an application to be considered as an Adopter or Foster of an equine (defined as a horse, pony, donkey, or mule) from Last Chance Animal Rescue, Inc. (hereinafter, “LCAR”), a 501(c)3 charitable, rescue organization located in Charles County, Maryland by truthfully providing information on this Pre-Adoption/Fostering Application.Today's Date Date Format: MM slash DD slash YYYY Anticipated Acquisition Date Date Format: MM slash DD slash YYYY Applying asAdopterFosterWhich horse are you interested in?PLEASE TELL US ABOUT YOURSELFLegal Name First Middle Last Legal Name of Spouse/Partner First Middle Last Your Email Over the age of twenty-one (21) yearsYesNoDate of Birth Date Format: MM slash DD slash YYYY Date of Birth of Spouse/Partner Date Format: MM slash DD slash YYYY Cell PhoneSpouse/ Partner’s Cell PhoneSpouse/ Partner’s Email Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (if different)Employers NameHow long have you worked there?Have you or any one in your household ever been convicted of animal cruelty?YesNoIf "yes", please provide date(s), Jurisdition(s), and details.PLEASE PROVIDE INFORMATION RELEVANT TO HORSE OWNERSHIP AND/OR ACTIVITIESDo you currently own equine?YesNoIf “yes,” please describe how many, what breed(s), type(s), and age(s).Ever owned an equine prior to this?YesNoIf “yes,” date acquired & for how longIf “no,” how do you plan on acquiring the knowledge and skill to care for this equine?Do you considered yourself to be New to equine ownership Novice/Limited Experience Substantial Experience ExpertIs this equine for your own use or for a minor child? Own use For a ChildIf for minor Child, is the Child New to equines Novice/Limited Experience Currently taking riding lessons More than 2 yrs of lessonsWhat are your intended uses for an equine? Sanctuary care only Pleasure or trail riding Sport or Competition Lesson ProgramIf "lesson program", please explainAre there other animals on the property where the Equine will reside?YesNoIf "yes" Horse or other Equines Other Livestock Dogs Cats Poultry/FowlOther animals on the property?PLEASE PROVIDE INFORMATION RELEVANT TO CARE OF YOUR EQUINEName of VeterinarianPhoneEmail Name of FarrierPhoneEmail Will the Equine be living on your property?YesNoNumber of pastured acreageType of fencingType of shelter(s)Name of Boarding FacilityLocationPhoneContact PersonPLEASE GIVE BOARDING HISTORY (LAST 3 YEARS)Current Boarding Facility’s NameStreet Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Operated by (name of owner/manager)Phone# of Years at boarding facilityPLEASE LIST YOUR REFERENCESPlease list persons familiar with your current or past handling of and involvement with horses.Three References (may include equine trainers, instructors, professionals, or personal)Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneRelationshipName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneRelationshipName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneRelationshipI hereby apply to adopt or foster an equine from LCAR upon the set terms and conditions set forth in the Adoption/Foster Agreement. As an inducement to LCAR to accept this application, I agree to provide a deposit of funds and, further, I warrant that all statements above set forth are true; however, should any statement made above be a misrepresentation or not a true statement of facts I accept that I may be rejected as an Adopter or Fosterer. Additionally, I understand LCAR is not obligated to provide any reason(s) for such rejection and shall not disclose the confidentiality of any persons contacted in seeking background information.AUTHORIZATION: Release of Information and Investigation of FacilitiesI recognize that as a part of the procedure for processing my application, information will be obtained through personal interviews with others with whom I may be acquainted. This inquiry may include information as to my character, general reputation, and personal characteristics.I agree to permit an investigation of my current and/or prior boarding arrangements (which may include an on-site visit) and listed references for the purposes of determining my acceptance as an Adopter or Fosterer of an equine. I agree not to hold LCAR or any individual involved in the investigation liable for any perceived or real causes of action, including, but not limited to, defamation of character.AGREEMENT TO EXECUTE AN ADOPTION CONTRACTIn the event I am approved for adoption or fostering, I agree to execute an adoption/fostering contract detailing the terms and conditions for adopting or fostering an equine from LCAR, including but not limited to, price, delivery, ownership rights, and guidelines.DEPOSIT OF FUNDSI agree to provide a deposit in the amount of $200.00 (Two Hundred Dollars) along with this application. If approved for adoption or fostering, the deposit shall be applied toward the full adoption/fostering fee as agreed to in the Adoption/Foster Agreement. In the event LCAR disapproves the adoption or fostering, the deposit shall be refunded within ten (10) days after notification of denial. In the event I decide not to adopt or foster an equine from LCAR, I agree to forfeit the deposit as consideration to LCAR for the time and effort taken to review this application, contact references, and make an investigation. Current fees for adoption/fostering range from $600.00 to $3,000.00 depending on age, training, and traits of equine. The above information, to the best of my knowledge, is true and correct. I agree to permit LCAR to investigate the information and representations I have made known. If LCAR discovers any information to be false or misleading, I understand I will be denied the opportunity to adopt or foster an equine and also forfeit the $200 deposit fee.Full Name as Signature
