HENRY COUNTY HUMANE SOCIETY

HENRY COUNTY HUMANE SOCIETY
ADOPTION APPLICATION
Animals Name*
This questionnaire must be completed by anyone interested in adopting a pet from the Henry County Humane Society-Geneseo. We at the HCHS-G try to place our animals into permanent, responsible homes while matching the pet to you and your lifestyle.
NOTE: THE PROVIDING OF FALSE INFORMATION HEREIN WILL RESULT IN THE FORFEITURE OF ADOPTION FEES AND ANY ANIMALS ADOPTED.

All questions marked with * are required, if they do not apply please select or answer N/A.
We reserve the right to refuse an adoption based on poor or incomplete vet history.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone*
Email*
example@example.com
1. How long have you lived at the above address?*
2. What Type of pet are you looking for?*

DogCatPuppyKittenOther
Please indicate the reason for adopting a pet (Check all that apply)*

Family PetChilds PetCompanionWatchdogHunting DogBarn Cat/MouserCompanion for PetOther
4. Are you currently employed?*

YesNoIf no, is someone else in the household employed?
5. Are you 18 years of age or older?*

YesNo
6. Are you interested in adopting for:*

YourselfFamilySomeone Else
7. Do you live in a:*

HouseApartmentCondoMobile HomeDuplexTownhouse
8. Do you own your home?*

YesNo
If no, does your lease allow pets?*

YesNoN/A
List landloard phone number so we are able to contact them
Please enter a valid phone number.
9. Who lives in your household?*
Do all members know that you plan to adopt a pet?*

YesNo
10. What are the ages of any children in your household?*
11. Does any member of the household have any allergies?*
12. Will an adult be home during the day?*
13. Who will be responsible for taking care of your pet?*
14. If adopting a dog or puppy:
What procedures will you use for housebreaking?*
How will you handle chewing or destructive behavior?*
15. If adopting a cat or kitten:
How will you handle scratching or destructive behavior?*
16. Have you ever adopted from the Henry County Humane Society-Geneseo or another shelter?*

YesNo
If yes which shelter and where is that pet now?
17. How many cats and/or dogs have you owned in the last 5 years?
Dogs * Cats *
Where are these pets now? (Be specific)*
18. Have you ever turned an animal into the Henry County Humane Society-Geneseo or another shelter?*

YesNo
If yes under what circumstances*
19. Have you ever had to give up one of your own pets?*

YesNo
If yes under what circumstances
20. Has a dog died on your premises of distemper, parvo or unknown causes in the last three months?*

YesNo
21. Has a cat died on your premises of distemper, leukemia or unknown causes in the last three months?*

YesNo
22. Do you currently own a pet?*
List the animals' names with age, sex and breed:
23. Do/did your current/past pets live indoors or outdoors*
24. Are/were your current/past pets shots up-to-date?*

YesNoIf no, explain
25. Are/were your current/past pets spayed or neutered?*

YesNoIf no, explain
26. Are/were your dogs on heartworm preventative?*

YesNoIf yes which brand/product
Where do/did you purchase heartworm preventative?*
27. Current/most recent Vet Clinic used*
Phone
Additional Vet Clinics that have cared for your pets
Phone
In whose name are the vet records listed (if other than you)
28. Are you willing to go to the expense and trouble of taking your new pet to a veterinarian for full preventative healthcare AT

LEAST once a year and at other times when it is needed?
28. Are you willing to go to the expense and trouble of taking your new pet to a veterinarian for full preventative healthcare AT LEAST once a year and at other times when it is needed?*

YesNo
Where will your new pet live?*

IndoorsOutdoorsBoth
Where will your pet sleep?*
30. Is there a yard available?*

YesNo
If yes, is the yard completely fenced?
31. What do you plan to do with your pet when you go on vacation?*
32 If you have to move what would you do with the animal?*
Personal References:
Name*
Phone Number*
Name*
Phone Number*
We reserve the right to have inspections of the pet and the living conditions at any time. I authorize HCHS-G to contact the veterinarian office named above to confirm the medical records/history of my pets.
Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

HENRY COUNTY HUMANE SOCIETY

ADOPTION APPLICATION

NOTE: THE PROVIDING OF FALSE INFORMATION HEREIN WILL RESULT IN THE FORFEITURE OF ADOPTION FEES AND ANY ANIMALS ADOPTED.

Personal References: