DOG ADOPTION APPLICATION FORM

About the dog you wish to Adopt:

Names of the Fond du Lac Humane Society Dogs You wish to Adopt:

1st Choice:

2nd Choice:

3rd Choice:

What is your Ideal dog and why?

Desired Age:

Desired Size:

Desired Breed:

Desired Gender:

Male/Neutered Female/Spayed

Willing to Adopt:

Outgoing/Hyperdog Shy Dog Dog that needs training Dog that needs grooming None of these

Estimated hours dog will spend alone each day?

Where will the dog spend time during the day? (describe)

Where will the dog spend time during the night? (describe)

Which member of the household will have the responsibility of feeding your pets:

Which member of the household will have the responsibility of training your pets:

Which member of the household will have the responsibility of general care for your pets:

Please tell why you would like to adopt and animal from us?

Gift Companion To Breed For a child For a companion to another pet

It may take up to a month or longer for your new pet to adjust to other pets in its new home. Are you prepared to allow it this much time?

Yes No

Have you applied to adopt or adopted from the FDLHS before

Yes No

Do you agree to keep this dog as an indoor dogs?

Yes No

Are you willing to work on house training?

Yes No

Do you have a fenced in yard?

Yes No

Are you willing to participate in dog training classes?

Yes No

Will your dog be exercising outdoors?

Yes No

How many hours per day/week.

With some dogs we require home visits with potential adopters before the dogs can be adopted - Is this something you are okay with?

Yes No

Has anyone in your household ever been convicted of a charge related to cruelty to aniimals or child abuse?

Yes No

Any charges pending?

Yes No

Personal References #1 (Please List A NON-RELATIVE);

Name and Phone

Personal References #2 (Please List A NON-RELATIVE);

Name and Phone

Staff Note:

By signing below, I certify that the information I have given is true and that I recognize that any misrepresentation of facts may result in my losing the privilege of adopting a pet. I understand that FDLHS has the right to deny my request to adopt an animal and I authorize investigation of all statements in this application.

Signature

Date

ALL INFORMATION CONTAINED IN THIS APPLICATION WILL REMAIN CONFIDENTIAL AND THE PROPERTY

OF THE FDLHS. All Dogs MUST have a leash, before they can leave the shelter. *As a FDL Humane Society

applicant, I understand that I will be handling animals. I understand that in handling animals I may undertake any number of risks. I understand that in assuming this I may be exposing myself to potentially significant health risks or serious medical conditions, including, but not limited to: injuries from slips and/or falls, bites and scratches, infectious diseases, parasites, and allergic reactions (e.g. rabies, fleas, ringworm, and asthma Approved Applicant Waiver *Since many animals that come to the FDL Humane Society are from unknown backgrounds and are therefore ultimately unpredictable, I am thus aware that the FDL Humane Society is not in a position to know and makes no representations with the temperament, health or condition of any animal. In particular. I must rely on my own judgment and I understand and agree that by handling the animal, as an applicant I do so at my own risk. *Therefore, I agree to hold harmless, the FDL Humane Society, its employees, volunteers, agents, or directors, whether collectively or individually, for any injury or liability the animal(s) may cause to me. I further assume any and all liability for damages or to other persons, which may be caused by any animal(s) while in my care as an applicant, and hold the FDL Humane Society harmless therefrom. Please Print

Name/Date:

Date

Signature:

Clear

Witnessed By:

4 | F O N D D U L A C H U M A N E S O C I E T Y – D O G A D O P T I O N A P P L I C A T I O N

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

DOG ADOPTION APPLICATION FORM

Your Contact Information

Family and Housing