POH Adoption Application Sept 2018

Pound on the Hill Animal Rescue is a non-profit, animal welfare organization dedicated to improving the conditions for companion animals in poverty-stricken communities. We provide education and assistance for current owners to raise the bar on acceptable care in the community, work with civic leaders to implement better animal care and protection ordinances and through the rescue and placement of stray, neglected and abandoned animals. All of our rescued companions are cared for in foster homes or in one of our two small facilities located in the Birmingham Metro area. Each animal receives complete medical care prior to their adoption. In addition to addressing their medical needs, we strive to help the dogs to become better pets by working on issues which might prove to be problematic as a companion before they are considered ready for adoption. When the dogs are physically and emotionally fit to find their forever family, they are transported to Pound on the Hill - Massachusetts Chapter where they are matched with the best home. After a trial period with their new potential family the adoption process is finalized. We are funded solely through donations from concerned citizens and adopters.

Name of the dog you are interested in:*

Your full name:*

Your age:*

Street Address:*

City, State, Zip*

Main Phone:*

Area CodePhone Number

Work Phone:

Area CodePhone Number

Other Phone:

Area CodePhone Number

E-mail:

Employer:

Character reference and phone number:

Are all members of your household in agreement with this adoption?*

YesNoDon't Know

Who will be the pet's primary caregiver?*

Do you live in a*

Do you own or rent?*

OwnRent

If rent, provide name and phone number of landlord:

Does your landlord allow dogs?

YesNo

Are there any restrictions from your landlord or subdivision?*

NoneNumber of petsSize or weight restrictionsBreed restrictions

If number of pets restriction, please enter limit

If size or weight restriction, please enter limititation

If breed restriction, please enter excluded breed(s)

Do you have a fully fenced yard?*

YesNo

Height and type of fence

Do you have any of the following?

Underground fenceKennelDog Run

How many adults are in your household?*

How many children are in your household?*

If children, what are their ages?

Have your children been around animals before?

YesNo

Does anyone in your home have allergies to dogs or have asthma?*

YesNo

List any pets you own or have owned in the past five years, and their ages

How many of these pets are spayed/neutered?

Where are these animals now?

Have you adopted from an animal rescue group before?

YesNo

If yes, what group?

Have you ever given up a pet?

YesNo

If yes, what were the circumstances?

Please provide the name and phone number of your current and/or previous veterinarian or clinic:

Have you ever been charged with a violent crime? *

YesNo

If yes, please explain

Have you ever been charged with domestic violence?*

YesNo

If yes, please explain

Are you currently on supervised probation or parole*

YesNo

If yes, please explain

Do we have permission to run a background check to verify aspects of this application*

YesNo

If no, please explain

I understand that I assume full responsibility for the welfare of this pet from the date of adoption.

Adoption Application

Applicant Information

Household Information

Current/Previous Pet Information

Criminal Background