Adoption Application Step 1 of 4 - Personal Information 25% * = required fieldsApplicant 1 Name* First Last Applicant's age*This is mainly for ensuring the dog we give you is a good fit based on its personality. Applicant 2 Name (Optional) First Last Address* Street Address City Choose OneAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Type*MobileHomeBothHome Phone:*Cell Phone:*Work Phone:Email:* This pet is for:* Me Family Another Person If Another Please Explain:*Please explain why you are looking to adopt a animal, and what you are looking for in a that animal:*How many people live in your home?*List all Adults (over the age of 18) in your home not including yourself.NameRelationshipAge Click the + icon to the right of the "age" field to add more.NameRelationshipAge Click the + icon to the right of the "age" field to add more. Do children visit your home on occasion?* No Yes Please list their ages:*Is anyone in your home allergic to any animals?* No Yes Not Sure Please Explain:*You live in:* House Apartment Duplex Household is:* Quiet Active Does your home have a yard?* Yes No Is the yard fenced: Yes, it is fenced No, it is not fenced Do you:* Own Rent Live w/Parents Live w/Roommates Landlord's Name:* First Last Landlord's Phone Number:*Parent 1 Name:* First Last Parent 1 Phone Number:*Parent 2 Name: First Last Parent 2 Phone Number:Roommate's Name First Last PhoneAre you allowed to have pets?* Yes No Do all adult members of your household want to and/or agree to the adoption?* Yes No If not, explain:* Who will be your new pet(s) primary caretaker:*Are you interested in a specific Animal or breed?* Yes No Name or Breed:List any name of the animal in our program or breed(s) of dog you are looking for or put none. Preferred Dog Size: Teacup >=5lbs. Small 5-10lbs. Medium 11-35lbs. Large 35-70lbs. Very Large 70+lbs. Any Size Please note that Teacups and Small dogs can be medically prone and require special care.Preferred Dog Activity/Energy Level Low - Couch Potato Medium - Fit and likes to walk. High - Likes to Run and play. Any Energy Level Preferred Dog Age: 8 Weeks - 3 Months - Newborn Bottle Baby 3 Months -11 Months - Puppy / Kitten 1 - 3 Years - Young 4-9 Years - Mature Senior - Golden Years 10+ Any Age Where will you keep your pet during the day?* Inside Outside Where will you keep your pet at night?* Inside Outside How many hours in a day will your pet be home alone?*Check all that apply. Someone is usually always home 1-4 hours alone 8-12 hours alone I have a doggie door I come home on lunch break I bring my pet to work with me I plan to use doggie daycare I'm prepared to train my new pet for: Housebreaking Destructive Chewing Separation Anxiety The pet I adopt must:Check all that apply. Do well with children Do well with dogs Do well with cats Do well with Farm Animals Do well with strangers Be Doggy Door Trained Be Kennel Trained I would Spent the following on on a pet at a medical Visit:* $0 - $50 $51 - $250 $251 - $500 $501 - $1,000 Any amount needed for pet's needs I Use Pet Insurance Please Note this is for emergency medical treatment, not vaccinations or routine care.Personal History with Pets Please provide below a list of current and past animals you've owned.Do you have any Pets currently?* Yes Not Currently Never Are all your Pets Spayed and/or Neutered?* Yes No PetsPet Name:Breed / Type:Pet Came From:Age:Still With You?If not what happened? Click the + symbol on the right to add additional PetsAre your current pets up-to-date on all vaccinations, including rabies?* Yes No Are your current pets licensed? Yes No Under what circumstances would you give up a pet?*Have you ever had to give up a pet?* Yes No Please explain why and what happened:*Name of your Veterinarian: First Last Address of your Veterinarian: Street Address City State / Province / Region ZIP / Postal Code NameThis field is for validation purposes and should be left unchanged. Δ
Hearts 4 Paws Mailing Address
