Adoption Application
Name
First Name
Last Name
Confirm that you are at least 18 years old
Yes
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Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of dog applying for
Do you own or rent?
*
Own
Rent (Pets must be allowed by owner)
Will there be children in the home?
Yes
No
If you answered yes above please list ages below:
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Have you ever had to surrender or give away a pet?
Yes
No
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Reason for surrender
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Please list all pets currently in the household
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If you answered yes to having pets in the home, please list your vets name and phone number. We will contact to ensure pets are up to date on vaccines.
Would you adopt a dog with medical issues?
Yes
No
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Where in the home will pet sleep?
Inside
Outside
How many hours per day will the dog be alone?
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Are you willing to house train your dog if not housebroken?
Yes
No
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How do you plan to address possible behavior issues?
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I understand that Henderson Home Animal Rescue is not able to guarantee the health or temperament of the dog being adopted. I hereby release Henderson Home Animal Rescue from all liability once the dog is adopted.
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Signature
Should be Empty: