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 strangers 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 CommentsThis field is for validation purposes and should be left unchanged. Δ
Hearts 4 Paws Mailing Address
