For HAHS Use Only

For HAHS use only: /
Name of Animal Adopted: / Date:
Case #: / Shelter Number #:
Foster’s Name: / HAHS Tag Number:
HAHS to S/N before release:

HEART OF AMERICA HUMANE SOCIETY ADOPTION APPLICATION

PERSONAL INFORMATION

Name: / I am over 21: / YES / NO
Address:
City, State, Zip:
How long have you lived here?
Phone #: / Alternate (required):
E-mail Address:

ABOUT YOUR SELECTION

What age dog are you considering?
I want this pet to be a: (CHECK ALL THAT APPLY)
Breeding / Child’s pet / Gift
Hunting / Guard / Household companion
Working/Farm / Companion for another pet
Other (please explain):

FAMILY & HOME ENVIRONMENT

Do you live: / Alone / With parents / With spouse/partner/roommate
If children, please list names and ages:
I live in a:
House / Duplex / Mobile Home / Condo / Apt.
Other (please explain):
I own
Rent
Landlord’s name and phone #
Weight Limit: / Pet Deposit / Monthly Pet Fee
Are you expecting any life changes in the near future i.e. birth of a child, getting
married, moving?
Who will have the primary responsibility for care of this animal?

PET(S) LIVING ENVIRONMENT (CHECK ALL THAT APPLY)

Pet will be house pet, living inside with family, except for exercise and elimination.
Pet will live in basement, garage, porch, or sunroom.
Pet will live mostly outside, inside in bad weather.
Pet will live outside with a doghouse.
Pet will live strictly outside with access to a barn.
Other (please explain):
How many hours a day will pet be home alone?
When home alone, pet will be: (CHECK ALL THAT APPLY)
Loose inside house.
In a crate inside house.
In a crate until house trained.
In a garage, sunroom, or basement.
Outside in fenced yard.
Outside free to roam around.
Outside in secured kennel.
Outside secured to a chain or cable.
Will go to dog-day-care.
Other (please explain):
If you travel: (CHECK ALL THAT APPLY)
Pet will travel with me.
Pet will be boarded.
Pet will stay home alone.
Will have in-house pet sitter.
Pet will stay with friends/relatives.
Other (please explain):
How will pet be exercised? (CHECK ALL THAT APPLY)
Leash walk every day.
Will have cable or dog run in the yard.
Will be free to run in fenced yard.
Will have supervised access to unfenced yard.
Will be free to roam around (unsupervised in unfenced area).
Will bring to dog park.
Other (please explain):
Home yard size is: / Small / Medium / Large / Acreage
Is yard enclosed by fence?
No fence. / Plan to install/finish fence
Yard is partially fenced. / Yard has underground fence.
Yes, yard is fully fenced on all sides.
If fenced, please describe fence size and type:
Do you have a swimming pool? / YES / NO
Is there a doggy door? / YES / NO

OTHER PETS

List all other pets currently living in home:
Name / Breed / Age / Gender / Spayed/Neutered / Declawed
If you have other dogs or cats please describe current living situation:
(Inside, Outside, Crated, Loose, etc.)
If you have or had other pets in the past, please detail current disposition:
(CHECK ALL THAT APPLY)
Still have the pet(s). / Was killed by accident.
Died of old age. / Died of a fatal disease.
Was killed by vehicle. / Was stolen.
Disappeared/stolen / Sold.
Confiscated by animal control. / Found pet(s) a good home.
Ex spouse/partner kept after separation. / Was euthanized due to behavior problems.
Returned to shelter or adoption agency. / Gave to friends, relatives, or acquaintance.
Relinquished to animal shelter or rescue group.
In your opinion what is a good reason to get rid of a pet? (CHECK ALL THAT APPLY)
Pet allergies.
Divorce/Separation.
Financial issues
Moving to a home where pets are not allowed.
Not enough time for pet or home is too small.
If pet is destructive or not house trained.
If pet is aggressive towards other people or children.
If pet is aggressive towards other pets.
Other (please explain):
Who is your vet?
May we contact your vet for a reference: / YES / NO
What do you know about heartworm?
Are your dogs on heartworm preventative? / YES / NO
When is it taken:
Would you consider obedience training if needed?
How much do you expect to spend on a dog per year?
Will you take this dog to the vet for a first exam within 10 days? / YES / NO
Would you be willing to allow a representative of HAHS to visit your residence by
appointment? / YES / NO / UNSURE

MARKETING

How did you find out about this animal?
What was it about this animal caught your attention first?
Where did you hear about Heart of American Humane Society?
Petfinder.com / Petco
HAHS website / Petsmart
1-800-Save-A-Pet.com / Bea Martin Peck Animal Shelter
Television newscast segments / Lee’s Summit Animal Shelter
Referred by a friend / Referred by past Hahs adopter
Print advertisement: (CHECK ALL THAT APPLY)
KC Star / Overland Park Sun / Paw Prints: The Magazine / Other
Online calendar of events: (CHECK ALL THAT APPLY)
kccommunitynews.com/calendar / kcstar.com / pawprintskc.com / Other
I have answered all of the questions truthfully and understand that if any intentionally false statements have been given, this application will be void.
Signature / Date

For HAHS use only:

Arf approved / YES / NO
Foster approved / YES / NO
Approved by
Second signature (if required)
Denied and reason:

11-13-2008 Heart of America Adoption Application Page 1 of 4