Every animal is to be assessed individually. The information must be completed to the best of your knowledge. The Humane Society of Pinellas is a managed admissions no time limit shelter. Available resources, space/budget restrictions, age, health, temperament, foster home availability and behavior should be considered for each animal in question before a decision is made concerning surrender eligibility. This form must be filled out in its entirety. Detailed and honest information from you is crucial to our placement process, so please take the time to fill in this profile with care and accuracy. Undesirable behaviors and medical issues do not necessarily create problems in placement, however not disclosing those problems definitely does. This should not take more than 10 minutes or less.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
E-mail
Phone Number
-
Area Code
Phone Number
Dog's Name
Breed:
Sex:
Age:
Color:
Approximate Weight
Is your dog Spayed or Neutered?
Yes
No
Micro-chipped
Yes
No
If Yes, what is the number?
Have you made alternate attempts to place the animal? If yes, where?
Where did the dog originally come from?
Are you obligated to return the dog to the place/group/breeder you got it from?
Yes
No
What is the reason you are applying to surrender your dog to HSP?
How long have you had the pet? (If less than 30 days, who was the previous owner?)
Has your dog bitten or scratched anyone in the past 10 days, resulting in the skin being punctured?
Yes
No
If Yes, what was the circumstance?
Has the dog acted sick or behaved in an unusual manner during the past 10 days?
Yes
No
Does your dog have any medical/health conditions or allergies
Yes
No
Is your dog currently on medication?
Yes
No
If yes, what?
Has the animal been bitten or have any wounds or injuries or been exposed to any wild animal, living or dead, during the past year?
Yes
No
Can you provide proof of current Rabies vaccination?
Yes
No
Has your dog ever been to see a veterinarian?
Yes
No
If yes, how long ago was the dog examined?
Current Veterinarian :
Phone #
How does the animal behave at the vet?
Does your dog need to be muzzled at the vet?
Yes
No
Does your dog need to be muzzled in public?
Yes
No
How does your dog react to bathing and/or brushing?
How does your dog react to having his/her nails trimmed?
Are there any body parts that your dog does not like having touched? Please list
Is the dog housebroken?
Yes
No
Somewhat
Please explain
When is the last time your dog had an accident in the house?
Have any history of aggression (with people or animals)
Yes
No
If Yes, explain
Tolerate being left alone
Yes
Yes, if crated
No (barks, chews)
How does your dog walk on a leash? Check all that apply
Bites leash
Jumps
Pulls
Freezes
Other
Walks calmly with no pulling
Does your dog escape (or try) from the house or yard?
Does your dog react to new dogs outside of your home?
Yes
No
Has your dog been socialized? Check all that apply
Dog Park
Daily Walks
Pet Supply Store
Other
If Other, describe:
Describe your dog's behavior around other dogs. CHECK ALL THAT APPLY
Never been around
Adores
Friendly/Playful
Plays Rough
Aggressive with all dogs
Bossy
Frightened
Ignores/indifferent
Gentle/Submissive
Aggressive with small dogs
Aggressive with large dogs
Aggressive with same sex
Aggressive with unfamiliar dogs
Other: Explain
Does your dog play better with:
Male Dogs
Female Dogs
Small Dogs
Large Dogs
Cats
All
None
Would you recommend placing this dog in a home with other dogs?
Yes
No
Doesn't Matter
If no dogs, please explain
Please describe your dog's behavior around cats (check all that apply)
Never been around cats
respectful
Friendly/Playful
Aggressive
Has killed a cat or would kill a cat
Frightened
Ignores or Indifferent
Gentle/Submissive
Chases
Would you recommend placing this dog in a home with cats?
Yes
No
Doesn't Matter
If no cats, please explain:
Please check all the animals that your dog has lived with:
Male Dogs
Female Dogs
Male Cats
Female Cats
Large Dogs
Small Dogs
Senior Animals
Farm Animals
Pocket Pets, ie, guinea pigs, gerbils, hamsters
Where does your dog sleep at night? Check all that apply
Loose inside the house
In garage
Outside
In child's room
Confined to one room
In adult's room
On my bed
On dog bed
Couch or Chair
Crate
On Child's bed
Where is your dog kept when no one is home?
Free Run of the house
Crated
In fenced yard
In garage or basement
Confined to one room
Outside on chair or runner
Electronic Pet Containment
How many hours does your dog spend outside?
None
Less than an hour
1-2 hours
3-4 hours
More than 5
Lived Outside
Allowed inside only at night
Allowed inside only in extreme weather
How is your dog confided when outdoors?
Fenced Yard
Electronic pet containment
Dog House
Tied Out (chain or runner)
Kennel or enclosure
loose
If the dog is confined by a fence, how high is it?
What type of fencing material?
Has your dog ever wandered or run away?
Yes
No
If yes, how often?
What training/performance activities has your dog participated in? Check all that apply
Home trained
Obedience classes
Flyball
Herding
Therapy dog certification
Fieldwork
Agility
Other:
Has your dog ever done the following? Check all that apply
Adult Family Members
Barked
Lunged
Growled
Snapped
Bitten
None
Children Family Members
Barked
Lunged
Growled
Snapped
Bitten
None
Strangers at the door
Barked
Lunged
Growled
Snapped
Bitten
None
Visiting Adults
Barked
Lunged
Growled
Snapped
Bitten
None
Visiting Children
Barked
Lunged
Growled
Snapped
Bitten
None
Vet or Groomer
Barked
Lunged
Growled
Snapped
Bitten
None
Pedestrians
Barked
Lunged
Growled
Snapped
Bitten
None
People near his/her food
Barked
Lunged
Growled
Snapped
Bitten
None
Neighborhood Pets
Barked
Lunged
Growled
Snapped
Bitten
None
How do you know when your dog needs to go outside?
When does your dog's housetraining accidents usually happen? Check all that apply
When dog is unsupervised
When dog is not kept on schedule
Never
When dog is over excited
When dog signals to be let out are ignored
How have you dealt with housetraining problems (check all that apply)
Consult Vet or Trainer
Paper Training
Confined Dog
Kept dog outside
Rubbed nose in it
Yelled at dog
Spanked dog
Acted "mad" at the dog
Ignored
Other
Do you trust your dog off leash?
Yes
No
Sometimes
Does your dog run after cars, bikes or pedestrians?
Yes
No
If yes, what does the dog do when he/she gets close to them?
Has your dog ever been kenneled?
Yes
No
How did your dog react?
Is your dog crate trained?
Yes
No
If yes, how long did your dog spend in the crate each day?
Is your dog destructive when left alone inside the home? Check all that apply
Chews woodwork/walls
Chews Furniture
Chews clothing/shoes
Chews paper or trash
Chews toys/stuffed animals
chews crate
Chews on windows/doors
Digs
Marking/Urinating
Does the dog bark when left alone?
Yes
No
What commands does your dog understand? Check all that apply
Sit
Stay
Down
Heel
Come
Leave it
Drop it
Off
Fetch
No
Get out
Verbal
Hand Signals
None
Other
Please describe your dogs behavior in the car
Looks out closed window
paces
Drools
Whines
Barks
Sleeps
Calm
Car Sick
Destructive
Urinates
No reaction
Sits
Lays Down
Excitement
Never Rides in the car
Is your dog protective or possessive of anything? Check all that apply
Food (with other pets)
Toys (with other pets)
His/Her Body
Vehicle
Food (with people)
Toys
Owner/Family
Of Property
Animal Companions
Bones
Does your dog run/hide or growl/nip at any of the following? Check all that apply
Babies/Toddles
Men
Women
Teenagers
Dogs
Cats
Strangers/Visitors
Loud Voices
Thunder/Lightening
Car
Sudden Movement
Vacuum
Vet/Groomer
Fireworks
Loud Noises
Plastic bags
What are your dog's favorite activites and toys? Check all that apply
Shows no interest
Frisbee
Squeaky Toys
Daily Walks/Jog/Hikes
Tennis Balls
Rope Toys
Shoes
Dog Park
Beach Play
Children's toys
Tug of war
Fetch
Car Rides
Option14
Describe your dog's play style with people. Check all that apply
Plays Gentle
Plays rough, but stops when told
Plays very physically
Pefers to chase
Just likes to hang out
Tends to herd
Tends to nip
jumps and uses mouth to play
no interest in playing
Did your dog live with children in your home?
Yes
No
If yes, what ages?
Would you recommend placing the dog in a home with children?
Yes
No
Why or why not?
Do you have children as visitors in your home on a regular basis?
Yes
No
Were all interactions between your dog and children supervised by an adult?
Yes
No
If yes, please explain:
Describe your dog's behavior around children (check all that apply)
Never been around kids
Friendly/Playful
Gentle
Plays Rough
Runs Away/Hides
Snappy at times
Aggressive
Jumps
Too Active
Adores Children
Protective
Avoids Children
Will your dog allow children to touch or handle food/bones without getting upset?
Yes
No
Will your dog gently take treats offered by children?
Yes
No
If No, explain:
Have children fed or watered your dog on a daily basis?
Yes
No
N/A
Does your dog accept being brushed or petted by children?
Yes
No
Unknown
Will your dog accept roughness from children of any age (having ears tugged, eyes touched, tail held/yanked, or full pulled?
Yes
No
Unknown
If no, explain
Has a child ever tripped over, stepped on, or fallen on your dog?
Yes
No
How did the dog react?
Please describe if your dog would react negatively in any of the following situations: A child Running, Falling Down, Child Jumping, Child Throwing a ball/toy
Please describe your dog's most likely to the reaction to the following situations:
Child Running
Child Falling Down
Child Jumping/Hopping
Child Throwing a ball
A child yelling/screaming
A child jumping on the dog
A child waving arms or other unexpected movements
How will your dog react to a child approaching when he/she sleeps
Describe how the child plays with the dog
Is your dog possessive or guarded about where he/she sleeps?
Yes
No
Does your dog dislike men or women? Please explain your dog's reaction to each
How does this dog react to strangers in the home?
How does your dog react to strangers outside the home?
Are there any additional comments ou would like to make that would be helpful to familes considering adopting him/her?
By submitting this application, you certify that information contained in this application is true and complete. I understand that false information may be grounds for dismissing this application immediately. I authorize the verification of any or all information listed above. HSP is a managed admissions shelter. We have the right to refuse admission to our shelter. While we provide above and beyond care for our animals, we reserve the right to humanely euthanize an animal that becomes "not adoptable" during its time in our facility.
Submit Form
Should be Empty: