Dog Admissions Application

The Jefferson County Humane Society does not euthanize animals to make space for others. Adoptable animals remain in our care until they find a loving home which may be a matter of days or much longer. Therefore, space is limited and becomes available as animals are adopted. Large dog space (over 30 lbs) becomes available less frequently than small dog/puppy space because it typically takes them longer to be adopted.

While the application below may seem long, we ask these questions so that we're able to find the best new home for your animal based on its past history.
Once your application is submitted your animal will be added to our wait list and we will contact you as soon as we have space for your animal.
Once we review your application, we may contact you if we need additional information.
If you are able to rehome your animal before we find space to bring him/her into our facility, please call us at (740) 314-5583 so that we may remove your animal from our waiting list.
We make every effort to admit animals as quickly as possible.
We request a donation of $25 for admission of a dog to our facility if you are able to help to offset the cost of its care.

What type of animal do you need to surrender? *	Dog
First Name: *
Last Name: *
Street Address: *
City: *
State: *
Zip Code: *
Phone Number: *
Email Address:
Confirm email
Why do you need to surrender this animal? *
Please choose the option that best describes the dog(s) you need to surrender: * If choosing the option "Multiple Dogs", please submit a separate Admissions Application for each dog.	Single Dog Multiple Dogs Litter of Puppies (with mom) Litter of Puppies (without mom)
Please provide a description of the dog you need to surrender: * Breed if known, male/female, age, color, spayed/neutered, hair length, size, etc.
If you're surrendering puppies without a mom please state the reason why: * (i.e. keeping mom, location of mom unknown, mom is deceased, etc.)
Approximate age of puppies: *
How many puppies do you need to surrender? *
What are the puppies eating? * Check all that apply.	Still nursing from mom Being bottle fed formula Canned food Dry Kibble Not eating I don't know
Do the puppies have any of the following medical conditions? *
If you answered "Other" to the question above, please describe the medical condition(s): *
Where are the puppies currently located? *	Inside Outside
Dog's Name:
Breed:
Dog's Age: *
Dog's Sex: *	Male Female
Where did you get this dog? *
Why are you surrendering this dog? *
How long have you had this dog? *
Is the dog spayed or neutered? *
What is your relationship to this dog? *	Owner Caretaker Other
If you selected "Other" please specify your relationship to this dog: *
Including yourself, list the ages and genders or any other people living in your home: *
List any other animals your dog has lived with: * (i.e. cats, other dogs, rabbit, etc.)
How does your dog typcally behave toward the following:
Men your dog knows: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Women your dog knows: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Children your dog knows: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Unfamiliar Men: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Unfamiliar Women: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Unfamiliar Children: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Dogs your dog knows: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Cats your dog knows: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Unfamiliar dogs: * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Unfamiliar Cats * Check all that apply.	Never encountered Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
Does your dog typically uncontrollably chase or attempt to chase any of the following? * Check all that apply.	Joggers Bicycles Vehicles Outdoor cats Squirrels/other small animals Birds Doesn't chase
How does your dog usually react when you or another family member does the following?
Give it a bath: * Check all that apply.	Never tried Enjoys Allows Afraid Shows teeth/growls Snaps Bites None of these
Brush it: * Check all that apply.	Never tried Enjoys Allows Afraid Shows teeth/growls Snaps Bites None of these
Wipe its feet: * Check all that apply.	Never tried Enjoys Allows Afraid Shows teeth/growls Snaps Bites None of these
How does your dog usually react when an unfamiliar person approaches or enters the yard or house? * Check all that apply.	Friendly Afraid Barks Shows teeth/growls Snaps Bites None of these
How many times per day does your dog go out to use the bathroom? *
Does your dog have accidents in the house? *
If your dog has accidents in the house, how often?
Where does the dog spend most of its time? *	Inside the house - runs free Inside the house - in cage Outside the house - runs free in neighborhood Outside the house - runs free in the yard Outside the house - in box/cage Outside the house - tied up Other
If you answered "other" to the question above please describe here:
How long is your dog normally left alone (without people) during the day? *	Never 1-3 hours 4-8 hours 9-12 hours More than 12 hours
When the dog is left alone, is it: *	Outdoors Free in home Confined to a room In a cage Other
If you answered "other" to the above question, please describe here:
When left alone, does the dog usually show any of the following behaviors: *	Destroy household items Urinate/defecate Bark Cry None of these
When you are home, does the dog usually show any of the following behaviors: * Check all that apply.	Destroy household items Urinate/defecate Bark Cry None of these
When the dog plays, does it typically: * Check all that apply.	Jump Growl Bark Bite lightly Bite hard None of these
Where does the dog usually sleep at night? *	Cage Floor Dog bed Couch Owner's bed Other
If you answered "other" to the question above please describe here:
What commands does your dog know? * Check all that apply.	None Sit Stay Down Come Heel Give paw
Has the dog ever chased or attempted to attack or bite a person? *
If yes, describe the incident(s): *
Has the dog ever bitten a person? *
If you answered "Yes" to the above question please describe the bite and the circumstances surrounding it in as much detail as posible: *
Has the dog ever seriously injured or killed a person? *
If yes, describe the incident(s). *
Has the dog previously been designated a nuisance, dangerous, or vicious dog? *
If yes, indicate the designation that was assigned, the date of designation, and in which county or city the designation was made: *
Has the dog ever attacked another domesticated species (i.e. dog, cat, livestock, etc.) resulting in injury? *
If you answered "Yes" to the above question please list the type(s) of animal(s) the dog has attacked and explain the details of the attack(s) in as much detail as possible: *
Has your dog seen a veterinarian before? *
If you answered "yes" to the question above please list the name and contact information for the vet(s): *
Does the dog have any past or present medical conditions? *
If you answered "yes" to the question above, please describe the conditions here: *
Is the dog currently on any medication or a special diet? *
If you answered "yes" to the question above, please list medications/diet here: *
What type(s) of food does your dog eat? * Check all that apply.	Dry Canned Table scraps
If there is any additional information you think would be helpful to know about the dog (likes/dislikes,favorite toys/games, things dog is scared of, bad habits, training history, dog's history, etc.) please list it here:
Please upload a photo of the dog here: Did you know....a photo can oftentimes help an animal get placed faster! Fosters are typically found quicker when they can see a picture of the animal they're being asked to foster so please don't skip this step!
Additional photo:
Additional photo:
At times we may be able to bring an animal in faster if we have a foster. Are you willing to foster the animal(s) until a permanent home is found? *
I hereby certify that I: *
Name and contact information for owner:
By signing my name here I certify that the information I have given the Jefferson County Humane Society above about this animal's age, health and disposition is correct and that I have truthfully acknowledged any dangerous behavioral characteristics and any past history of biting or aggressive behavior. *