Bertie County Humane Society Adoption Application

Bertie County Humane Society Adoption Application

Thank you for considering pet adoption! To help us place our animals in safe, loving homes, we ask you to tell us about yourself, your home, your pet history, your pet‑care practices, and review the adoption agreement to electronically sign.
Animal Preferences

Share your animal preferences
Animal Name(s) Interested in Adopting
No specific dog in mind? Want us to help find your best match? Just enter “Any!”
In a short summary, please describe why you are seeking pet adoption or why you are most interested in this animal
Do you have any personal preferences regarding certain breeds or temperaments you feel would fit best with your lifestyle?
Examples of temperament traits: social butterfly, loves car rides, couch companion, good with kids, good with other dogs, confident, shy, eager-to-please, playful, food-driven, etc. You may also describe the types of activities you enjoy (e.g., hiking, swimming, brewery visits, dog parks, training, car rides, etc.).
Do you have any personal preferences in the size of pet you’d like to adopt?
What energy level do you prefer in a dog? (Energy level refers to how much physical and mental activity a dog typically needs. For example, a low‑energy dog may still enjoy going to breweries or relaxing social outings, while a high‑energy dog may prefer play, training, or structured activities but not necessarily hiking or long adventures. Choose the level that best fits your lifestyle.)
Applicant Information

Share your information
Applicant Name

First NameMiddle NameLast Name
Co-Applicant Name

First NameMiddle NameLast Name
Address (Where the pet will reside)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please provide a picture of the front of your drivers license

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Driver’s License Number
This helps us verify your identity if the photo is unclear.
Driver’s License State
This helps us verify your identity if the photo is unclear.
Occupation Details
Are you a college student?
Travel Frequency
Personal References

Share two personal references who can speak to your responsibility, character, and experience caring for pets.
Reference 1 Name

First NameMiddle NameLast Name
Reference 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 Email
example@example.com
Reference 1 State Located In
Reference 1 Details
Reference 2 Name

First NameMiddle NameLast Name
Reference 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Email
example@example.com
Reference 2 State Located In
Reference 2 Details
Household Information

Share details about your home
Length of Time at Current Address (Years)
Type of Home

Other
Rent or Own
Landlord Information
Landlord Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are there any rules or regulations at your residence that restrict pets—such as size, weight, breed, or the number of animals allowed?
Please describe the restrictions, including any limits on size, weight, breed, or number of animals, and indicate who enforces them (HOA, landlord, insurance provider, or local ordinance).
Do you plan to move within the next year?
Do you have a fenced in yard?

Other
Please upload a photo of your yard or the area where the dog will spend time outdoors.

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Does anyone in the home have allergies or concerns about dogs?
Household Members and Ages
Pet History & Information

Share your pet history
Do you have Pet(s)?

Other
Pet Details
Have you ever had to surrender, rehome, or return a pet to a shelter, rescue, breeder, or another individual?
Please provide details, including the reason, approximate date, where the pet was placed (shelter, rescue, breeder, another owner) and any other relevant information.
Do you have livestock?
Livestock Details
Veterinarian Clinic or Doctor Name
If you do not currently have a veterinarian, please list the clinic you plan to use.
Veterinarian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Veterinarian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Petcare Responsibilities

Share your comfort level and care plans for the different aspects of caring for a pet.
Comfort level with house training

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Comfort level with crate training (if needed)

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Comfort level with basic obedience training

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Comfort level with training for problem behaviors (jumping, digging, leash pulling, barking, counter-surfing, mouthiness/play biting)

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Comfort level with working with shy or fearful dogs

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Comfort level providing mental and/or physical enrichment (exercise, puzzle toys, training games, scent work, structured play)

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Comfort level with grooming needs (brushing, bathing, nail clipping, professional grooming, shedding management)

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Comfort level with caring for - and financially supporting - dogs with medical needs

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Comfort level providing monthly flea / tick / heartworm prevention (Typical cost is $20–$40/month or $120–$240 for a 6‑month supply. Heartworm prevention is prescription‑only. Fleas, ticks, and mosquitos remain active year‑round, regardless of climate or how often a pet goes outdoors.)

1

2

3

4

5

1 is Not comfortable, 5 is Very comfortable and experienced
Where will the pet stay when adopters/family are at home?
Where will the pet stay when adopters/family at night or when sleeping?
Where will the pet stay when adopters/family are away at work or running errands?
Who will take care of the pet when adopters/family are traveling or on vacation?
Note: All adopted pets need a decompression period to adjust to their new home. This may include quiet time, gradual introductions, predictable routines, and patience as the pet settles in. BCHS is happy to provide guidance and resources to support you during this transition.
Required Acknowledgments

We work hard to ensure every animal we place finds a safe, loving, and responsible home. Before adopting, we ask that you review and agree to the following commitments. These acknowledgements help us make our adopters understand the care, responsibility, and support that come with giving one of our animals a forever home.
Adopter agrees to provide appropriate care, housing, and veterinary treatment, including annual exams, vaccinations, flea/tick prevention, and heartworm prevention.
Adopter agrees to comply with North Carolina sterilization laws and provide proof of spay/neuter if the pet is not sterilized before adoption.
Adopter agrees not to surrender this pet to any shelter, pound, or animal control facility. If unable to keep the pet, adopter will contact BCHS for assistance.
Adopter agrees that this pet will live primarily indoors as a family member and will receive affection, companionship, and humane treatment.
Adopter agrees that this pet will not live outdoors full‑time and will not be chained or tethered as a primary means of confinement.
Adopter agrees to contact BCHS if euthanasia is being considered for medical, behavioral, or any other reasons.
Adopter agrees to contact BCHS before rehoming this pet to any rescue, foster, adopter, friend, family member, or other party. BCHS must approve any transfer of ownership.
Adopter agrees to keep the pet’s microchip registered (if applicable) with current contact information and update it if they move or change phone numbers.
Electronic Signature Block

Thank you for choosing to adopt a rescue pet! By adopting from Bertie County Humane Society, you agree to provide loving, responsible care, including proper housing, nutrition, veterinary treatment, and heartworm prevention. You agree to comply with North Carolina sterilization laws and provide proof of spay/neuter if the pet is not already sterilized.You agree not to surrender the pet to any shelter, nor to breed or sell the pet. You agree this pet will not be used for any unsafe, exploitative, or harmful activity, including fighting or baiting. If this pet participates in hunting, working, or sport activities, you agree these activities will be humane, legal, and appropriate for the dog’s temperament and physical ability.You agree this dog will not live outdoors full‑time and will not be chained or tethered as a primary means of confinement. You agree to contact BCHS if you experience behavioral challenges and would like guidance or resources. If you are ever unable to keep your pet, you agree to contact BCHS so we can help with next steps.We make no guarantees of health or temperament, but we are always here to support you and your new family member.
Liability Statement
- I understand that animals may behave unpredictably.
- I agree to assume all risks associated with adopting a pet.
- I release the Bertie County Humane Society from liability for injuries, damages, or expenses that may occur while the pet is in my care.
- I agree to follow all instructions provided by the Bertie County Humane Society or its rescue partners.
BCHS may reclaim the pet if the adoption agreement is violated.
Agreement to Electronic Signature and Terms
Typed Name

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Number of Household Members and Ages (one age per household member)
Should be Empty:

Bertie County Humane Society Adoption Application

Animal Preferences

Applicant Information

Personal References

Household Information

Pet History & Information

Petcare Responsibilities

Required Acknowledgments

Electronic Signature Block