Adoption Application
Seniors For Seniors Program
What is the name of the ANIMAL or ANIMALS you are interested in adopting?
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This animal is a: (dog, cat, other)
Your Name
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First Name
Last Name
Are you over the age of 62 (ID required at the time of adoption)?
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Please Select
Yes
No
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
May we text you at this number?
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Please Select
Yes
No
Email
*
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived in your current home?
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What type of dwelling do you live in?
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Please Select
Apartment
Condo
House
Trailer
If you live in a trailer court, which one?
Do you currently rent or own your home?
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Please Select
Rent
Own
Landlord's Name
Landlord's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How many people live in your home?
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What are the ages of any children in your home?
Does anyone smoke INSIDE the home?
Yes
No
Have you ever been convicted/charged with animal cruelty or neglect? If yes, when?
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How many pets do you currently have?
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List Names, Species, Breeds, and Ages of your CURRENT animals:(if you don't have animals, please enter NONE)
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Rows
Name
Age
Breed
Dogs
Cats
Farm Animals
Exotics
Please list any animals you've had in the PAST 5 YEARS (include names, type of pet, breed, age, sex, spayed/neutered status, indoors or outdoors pets).
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Will your new pet be kept inside, outside, or both?
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Please Select
Inside
Outside
Both
Do you have a fenced in yard?
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Please Select
Yes, a wireless fence
Yes, a secure physical fence
No
Who is your current veterinarian? (If you do not have a current vet, who do you intend to use as a vet for this pet?)
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First Name
Last Name
Phone number of vet:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the vet listed above, your current or future veterinarian?
Please Select
Current
Future
Please call your veterinarian and allow the release of your pet's medical records to us.
What name is the vet account under?
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First Name
Last Name
Are your animals up to date on shots?
*
Please Select
Yes
No
I don't have any animals at this time.
Are your animals spayed/neutered?
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Please Select
Yes
No
I have no other animals at this time.
If your current animals are not up to date on their shots and/or are not spayed/neutered, please explain why.
What is it about this particular animal that draws your interest?
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If your selected dog or cat has already been adopted, would you be interested in another if we were to suggest a similar animal?
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Please Select
Yes
No
Where and with whom will your pet spend most of his/her time?
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Are you aware that the dog you want to adopt may need to be re-house-trained due to them being in a kennel environment, which is different than a home.
Please Select
Yes
No
If your adopted cat or dog has behavioral issues, how will you deal with those? (For example with a cat: What if he/she claws your furniture? Gets on surfaces you do not wish him/her to jump on? For a dog: What if he/she jumps too much? Nips at your hands too hard? Chews on shoes, etc.?)
Additional Comments:
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Reference #1 – Please provide the name and phone number of a NON FAMILY reference.
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Submit
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