PVCHS Dog Adoption Application
Date
Animal you are interested in adopting
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Abdi (Dog - D2022044)
Ace (Dog - D2024082)
Afia (Dog - D2022042)
Ball-E (Dog - D2022091)
Banana (Dog - D2023220)
Bingo (Dog - D2023102)
Blocks (Dog - D2024106)
Boomer (Dog - D2021231)
Bowser (Dog - D2024132)
Bruno (Dog - D2022100)
Chicken (Dog - D2023115)
Corndog (Dog - D2024134)
Daisy May (Dog - D2024081)
Ellie (Dog - D2023113)
Gurdy (Dog - D2024126)
Hip Hop (Dog - D2023182)
Julia (Dog - D2023185)
Juliet (Dog - D2024138)
Lightning Bug (Dog - D2022254)
Lily (Dog - D2024112)
Lucy (Dog - D2024130)
Robin (Dog - D2024114)
Romeo (Dog - D2024140)
Shining Armor (Dog - D2024093)
Shorty (Dog - D2022281)
Sneaky (Dog - D2024102)
Socks (Dog - D2024121)
Squid (Dog - D2024022)
Sully (Dog - D2023216)
Tamara (Dog - D2024120)
Ted (Dog - D2024113)
Tramp (Dog - D2024129)
Twilight Sparkle (Dog - D2024094)
Wyatt (Dog - D2024027)
Applicant's First Name(s)
*
Applicant's Last Name
*
Street Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Please use the following format 248-555-1212
Email Address
*
Please enter correctly as this is the main way we will contact you
Alternate Phone Number
Are you 18 or over?
No
Yes
Drivers License Number
Please check the main reason you plan to adopt a dog:
*
select
Companion
Family Pet
Child's Pet
Companion for another pet
Other
If you answered "other" above, please explain here:
Have you owned a dog before?
*
No
Yes
Who will be responsible for caring for the dog?
*
Do you own other pets at the current time?
*
No
Yes
If yes, please list their names, breeds, and ages.
Are your pets current on their vaccinations?
*
select
Yes
no
n/a
Are all of your pets spayed/neutered/fixed?
*
select
Yes
No
N/A
If you have pets, will they adjust to a new pet in the house?
select
Yes
No
Unsure
N/A
How many pets have you owned in the last 5-10 years?
What happened to them?
Veterinarian's Name
*
If you have never owned a pet please tell us where you would go.
Veterinarian's Address, City, State, and Zip Code
Again if you have never owned a pet please list where you would go
Veterinarian's Phone Number
Are you familiar with heartworm and heartworm prevention?
*
No
Yes
Do you own or rent your home?
select
Own
Rent
Someone else owns the Home
Someone else rents the Home
Please select your current residence type.
select
House
Apartment
Condo
Townhouse
Mobile Home
Other
If you answered "other" above, please explain:
No
Yes
How long have you lived at this address?
select
Less than one month
1-2 months
3-6 months
6-9 months
9-12 months
1-2 years
3-5 years
6-10 years
10 + years
If you rent, does your landlord and lease allow pets?
select
Yes
No
Unsure
N/A
If you rent, what is your landlord's name and phone number?
Including yourself, how many people live in your household?
Please list the ages & relationship of children who live in your home.
Is everyone in your household aware that you are planning to adopt a pet?
select
Yes
No
N/A
Does anyone in your household have allergies to dogs?
select
Yes
No
Possibly
N/A
On average, how many hours per day will your dog be left alone?
How much do you think the annual medical bills will be for your dog?
select
About $100
$100 - $200
$200 - $300
$300 - $500
$500 +
What would you do if the bills went over this amount?
Will this pet be predominantly living inside, outside, or both?
select
Inside
Outside
Both
Please provide a description of this pet's living conditions.
Where will the animal sleep?
select
In bed with me
In bed with my child
In a dog bed
In a kennel / crate
Wherever he or she likes
Outside
Other
If you answered "other" above, please explain:
How will you handle housebreaking?
How will you handle destructive behavior?
Will you keep the animal up-to-date on vaccinations and heartworm preventative?
*
No
Yes
If no, please explain:
Have you ever been convicted of abuse or neglect of a child or animal?
No
Yes
If yes, please explain:
What arrangements will you make for the care of your pets in case of an emergency?
select
Leave with family/friend
Boarding
Pet Sitter
Take with me/us
Other
If you answered "other" above, please explain:
What will you do with the animal when you go on vacation?
select
Leave with family/friend
Boarding
Pet sitter
Take with me/us
Other
If you answered "other" above, please explain:
For what reason(s) would you consider returning/giving up the animal?
What would you do with your animal if you had to move?
select
Take him / her with me
Give to family or friend
Return to shelter
Other
If you answered "other" above, please explain:
Are you willing to take responsibility for this animal for the next 10-20 years?
No
Yes
If no, please explain:
Have you ever surrendered a pet to an animal shelter?
No
Yes
If yes, please explain.
Have you ever had a pet euthanized?
No
Yes
If yes, please explain:
Do you have a pool?
No
Yes
Do you understand a dog needs to be taught pool safety?
No
Yes
Are you willing and able to exercise the dog on a regular basis?
No
Yes
By signing here, I certify that the information I have provided is correct and any misrepresentations of the facts will result in my losing my privilege of adopting an animal. I am authorizing PVCHS to contact landlords, associations and veterinarians. I am also aware that PVCHS cannot guarantee the health and temperament of the animal. I understand that this application is the property of the Parke-Vermillion County Humane Society Pet Adoption Center, and they have the right to approve or deny my request to adopt an animal.
*
Clear
