Thank you for being a caring and responsible pet owner. We hope that enrolling your pet onto the HEA program will bring you peace of mind knowing you have done the right thing by them. So as to collect a full profile and gain a full understanding of your pet’s needs, this form contains several questions for you to complete. We estimate it will take approximately 30 minutes to submit. If you have the following information available, please have it handy to complete each section Your pet’s microchip number Your pet’s vet details A list of any medications Vaccination dates Your pet’s date of birth (or as close as possible) A photo of your pet Second owner signature it should state – if applicable Home Ever After Client Agreement Step 1 of 24 4% Owner DetailsName* First Last Address* Address line 1 Town/suburb State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Date of Birth* DD slash MM slash YYYY Phone*Emergency Contact* First Last Phone* Animal DetailsPet's name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Do you have additional pets* Yes No Yes, How many*How many Additional Pets123456789101112131415 Operation This Agreement comes into operation in the event of my death, or if I have become physically incapacitated to care for my pet/s. I understand that in the event of my death or permanent physical incapacitation, RSPCA NSW will become the legal owner of my pet/s. I authorise/do not authorise RSPCA NSW to correspond with my executor to establish if they are aware of any family, friends or suitable carer who can take on the responsible ownership of my pet. Or, in the instance of my physical incapacity, where possible, RSPCA NSW will initially work with me in the same way to find an alternative responsible owner. Additional pet 1Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 2Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 3Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 4Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 5Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Microchip number (if known) Additional pet 6Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 7Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 8Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 9Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 10Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 11Pet’s name* Date of birth of animal*Sex of animalMaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 12Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 13Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 14Pet’s name* Date of birth of animal*Sex of animalMaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) Additional pet 15Pet’s name* Date of birth of animalSex of animal*MaleFemaleSpecies* Breed Colour (identifying descriptor) Microchip number (if known) The parties agree as follows: RSPCA, NSW agrees to accept the above-named pet into the RSPCA, NSW Home Ever After Program. I understand that by signing this agreement, in the event of my death, or if I have become physically incapacitated* to care for my pet/s, I surrender the animal/s named in this document to RSPCA NSW. At which time, RSPCA NSW will become the legal owner of my pet. At the time of entry into the Home Ever After Program, my pet will undergo a Veterinary Health Check and Behavioural Assessment to ensure re-homing suitability. Further, I understand that based on the evaluation of the above assessments, RSPCA, NSW retains the right to euthanise my pet for veterinary or behavioural reasons. *physically incapacitated is defined as permanent illness or injury where there the client retains legal capacity and can consent to the completion of this agreement. Where a client does not retain legal capacity RSPCA NSW will need to receive a signed surrender form from someone authorised to do so on the client’s behalf via enduring guardianship or power of attorney. For the purpose of this Agreement physical incapacity includes inability to care for animals due to conditions imposed in relation to housing, for example facilities which do not permit residents to have pets. Declaration I am 18 years of age or over and I am the legal owner / person in charge of this animal/s. I promise that the information under ANIMAL DETAILS above and/or overleaf is correct. No other person owns or has any proprietary interest in this animal or, if any other person has such an interest, they have authorised me to surrender the animal. I agree to indemnify RSPCA NSW and keep RSPCA NSW so indemnified against any and all proceedings and claims, costs and expenses whatsoever arising out of action by any person claiming interest in the animal. Liability a) This Agreement is binding upon the Client, the spouse of the Client, the next of kin, and /or any executor named in a Will or similar document evincing testamentary intention. b) This Agreement supersedes all prior discussions, representations, warranties and agreements of the parties, and expresses the entire agreement between Client and RSPCA, NSW for the purposes of my pet’s entry into the Home Ever After Program. c)The parties confirm that, except for that which is specifically written in this Agreement, no promises, representations or oral understandings have been made with regard to (pet/s name) or any other matter. d)This Agreement may be amended only by a written instrument signed by both Client and RSPCA Home Ever After Coordinator. SignatureName* First Last Date* DD slash MM slash YYYY Second Owner SignatureName* First Last Date* DD slash MM slash YYYY Witness SignatureName* First Last Date* DD slash MM slash YYYY Address* Address line 1 Town/suburb State Postcode Your compassion can help vulnerable animals in the years to come. RSPCA NSW does not ask for any payment for this program, but respectfully requests anyone who enrols their pets to leave a Gift in their Will instead. These future gifts, no matter how big or small, will ensure that RSPCA NSW can continue offering community programs like this one to pet owners in need, plus provide vital care and emergency assistance to vulnerable animals across the state.If you are comfortable to, please indicate your wishes below: I have already included a gift in my Will to RSPCA NSW. I intend to include a gift in my Will to RSPCA NSW. I do not intend to include a gift in my Will to RSPCA NSW. If you have already included a gift in your Will was your gift in memory of a pet, friend or relative? Yes No If yes, who was your gift in memory of/ inspired by? Thank you for your support. From the more than 24,000 animals who come through our doors ever year.Are you happy to be contacted about this by a member of the HEA team? Yes No
