SHELTER NO. ______
PRELIMINARY ADOPTION FORM FOR DOGS
Name ______Date: ______
Address ______
City ______State ______Zip ______
Home Phone: (______) ______Work Phone: (______) ______
E-mail Address: ______
1) Which dog are you interested in adopting? ______
2) Are you adopting for Yourself; Immediate family; Friend/relative; Other
3) Your Age: 18-22 years 23-26 years 27-30 years 31-40 years 41-50 years 51+ years
4) List others living in your household and age(s) of anyone under 18 years old: ______
______
______
5) Does anyone in the home have allergies to dogs? Yes No
6) Please indicate your reasons for adopting a dog: Family Pet Adult companion
Child’s pet (Child’s age: __) Guard Dog Hunting dog Companion for another pet
7) Who will be primarily responsible for the dog? ______
8) Indicate any of the following qualities that are important to you in a dog:
Large dog Small dog Kid-friendly Specific breed? ______
Please take advantage of our staff’s knowledge of JHS dogs and discuss anything specific you may be looking for in a
dog (i.e., spunky; obedient; quiet; friendly, etc.)
9) What is your living situation:
Own house Own mobile home Rent apt/Duplex In parent’s home
Rent house Rent mobile home Rent condo/Townhouse Other If “Other”, Please explain: ______
10) If renting, we must verify with your landlord that you may have a dog. Please list landlord’s name and phone number: ______
11) Do you expect any major lifestyle changes in the next two years? Marriage New Baby
Caring for Elderly Relative Other None
If “Other”, Please explain: ______
12) Will the dog be primarily: Outside In home Both If “Both”, please explain: ______
______
13) Is the yard: Partially fenced Fully fenced Not at all fenced
14) If fenced, what type of fence? Chain Link Privacy Invisible Other
If “Other”, please explain: ______
15) If no, how will you ensure your dog’s safety while outdoors and how will you see that it gets plenty of exercise? ______
______
16) Are you familiar with house training? Yes No
17) Are you familiar with crate training? Yes No
18) Where will the dog stay while owners are gone during work or school hours?
Loose in home Confined to an area in house Garage Barn
Outside Other (specify): ______
19) Where will the dog sleep at night?
Free run of home Confined/crated in home Barn/outside building
Pen/Kennel Fenced-in yard Tied/fastened to a run
20) How much would you plan to spend on this pet yearly (including food, extras, vet care)?
$50-100 $100-300 More than $300
21) Are you committed to providing this dog with necessary medical care and obedience training to ensure its well being in your home for its lifetime? Yes No
22) Do you currently have a veterinarian? Yes No If yes, please provide Veterinarian’s name and phone number: ______
23) How many hours a day is someone home (on average/not including sleeping hours)? ______
24) What problems would constitute a reason for giving up your pet? ______
______
______
NOTE: If for any reason, you can no longer provide a responsible, loving home for your pet, the Adoption Contract confirms your agreement to return the animal to the Jessamine Humane Society.
25) Please write some thoughts telling us what makes you the best possible owner for this dog: ______
______
______
______
______
26) Would you object to our verifying any of the preceding information? ______
Would you object to a visit to your home prior to adoption? ______
Would you object to a follow-up visit after adoption? ______
27) Please list particulars of pets now owned or owned within the past five years:
Pet No. 1 / Pet No. 2 / Pet No. 3 / Pet No. 4Dog or Cat?
(List breed, if known)
Male/Female
Spayed/Neutered?
Current age of pet?
Age of pet when
acquired?
Age of pet when
last owned?
What happened if no
longer owned?
Healthy/Vaccinated?
Any pet behavior
problems?
Thank you for completing this questionnaire. Please note that it is not our intent to invade your privacy. Our purpose is to find responsible, caring permanent homes for our animals. At the same time, we want to insure that you have found a suitable pet to enjoy for many years.
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