Form
Name
*
First Name
Last Name
Occupation
*
Age
*
Co-Applicant's Name
First Name
Last Name
Co-Applicant's Age
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Alt. Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Regarding the home you live in now: Do you own or rent?
*
Own
Rent
How long have you lived in this home?
*
Name of Landlord:
First Name
Last Name
Phone Number of Landlord:
-
Area Code
Phone Number
Do you have permission from your landlord to adopt a new pet? If so are there any breed or size restrictions and what are they?
Ages of all people living in the home:
*
Does everyone in the home share an interest in adopting a companion animal?
*
Does anyone in your home have allergies to animal dander?
*
May we visit your home prior to adoption approval?
*
Who will primarily be responsible for the care, training, and exercise of the animal you adopt?
*
Ages of family or friends who will be visiting your home regularly:
*
Name of the animal you are interested in adopting:
*
Please provide a description of the type of animal you would like to adopt: Breed/Sex/Age/Etc.
*
Who will the adopted animal primarily belong to?
*
Are you adopting this animal as a gift or for a friend or family member?
*
Would you consider an animal with special needs or that requires daily medication?
What energy level or activity level do you prefer?
*
Low Energy
Low to Medium Energy
Medium Energy
Medium to High Energy
High Energy
A new pet requires time and effort to adjust to a new environment or home. How long seems like a reasonable amount of time? Choose the answer you feel is the most accurate for you and your family:
*
A day or two
A week
A few weeks
A month to two months
Several months or longer
Please list any bad habits or behaviors that you or your family could not tolerate:
*
If the pet you adopt displays any unwanted habits or behaviors listed above how long would you work with the pet to correct the behavior?
*
Please list pet information for any animal you have owned in the past 5 years or own now: Pet #1 Name, Species, Breed, Sex, and Age and if you still own him or her:
Was pet #1 Indoor or Outdoor?
Please list pet information for any animal you have owned in the past 5 years or own now: Pet #2 Name, Species, Breed, Sex, and Age and if you still own him or her:
Was Pet #2 Indoor or Outdoor?
Please list pet information for any animal you have owned in the past 5 years or own now: Pet #3 Name, Species, Breed, Sex, and Age and if you still own him or her:
Was Pet #3 Indoor or Outdoor?
Please list pet information for any animal you have owned in the past 5 years or own now: Pet #4 Name, Species, Breed, Sex, and Age and if you still own him or her:
Was Pet #4 Indoor or Outdoor?
Please list pet information for any animal you have owned in the past 5 years or own now: Pet #5 Name, Species, Breed, Sex, and Age and if you still own him or her:
Was Pet #5 Indoor or Outdoor?
Did you provide routine Veterinary care for your pets?
Name of Veterinary Hospital or Clinic
First Name
Last Name
Phone Number of Veterinary Hospital
-
Area Code
Phone Number
Name of Any Alt. Vet Clinic Used
First Name
Last Name
Phone Number of Alt. Veterinary Clinic
-
Area Code
Phone Number
Please select from the following to best describe where the adopted animal will live:
*
Indoor Only
Indoor Mostly with Outdoor play and exercise
Equally Indoor and Outdoor
Mostly Outdoor
Always Outdoor
During the day when no one is home where will the animal will be kept:
*
Indoor
Outdoor
Where will the animal be kept at night?
*
How many hours per day will the animal be without a human present in the home?
*
Do you plan to crate or kennel train your adopted pet?
*
What brand of dog food do you plan to feed the adopted pet?
*
Does your yard have a fully secure, fenced area for the adopted pet?
*
What size area is fenced?
What type is the fence material is your fence made from?
How high is the fence?
Do you gates have locks preventing unauthorized entry into your yard?
Please explain what type of exercise your adopted animal will receive and how often each type of exercise will occur:
*
Will the animal ever be allowed to roam, play, potty off-leash? If so please explain when and where:
*
Will your animal receive formal obedience training?
Do your current animal(s) get along with other animals? Please explain if there are any concerns with your animal adjusting to another.
*
Have you ever given away, sold, or surrendered, an animal? If yes, please explain the circumstances:
*
Are you aware that annual veterinary care is required by Louisiana State Law?
*
Are you aware of the state and local ordinances concerning licensing and leashing?
*
Our Adoption Contract requires annual veterinary care as well as monthly flea and heart worm prevention. This will be required if you adopt an animal from our rescue. Do you agree that you will provide annual exam, fecal and heartworm testing, vaccinations, monthly prevention and anything else needed or recommended by your Veterinarian?
*
If you were to move would your pet move with you?
*
What will you do with your pet should you have to evacuate for a hurricane?
*
If you have to travel what will you do with your pet while you are away?
*
Have you, or anyone in your home, ever been cited for leash law violation or cruelty to animals in the past? If yes, when and please explain:
*
Please tell us why you are wanting to adopt this pet:
*
Please tell us about your lifestyle and any activities your pet will be included in:
*
If you have a specific breed, age, or requirement for an animal please list it here so we can help find another pet should the one you're interested in already have found a home.
Personal Reference #1
*
First Name
Last Name
Reference #1 Phone Number
*
-
Area Code
Phone Number
Reference #2 Name
*
First Name
Last Name
Reference #2 Phone Number
*
-
Area Code
Phone Number
I attest that the information provided on this application is accurate and true.
*
yes
no
I understand that completion and submission of this application does not guarantee adoption of a pet from Animal House Rescue.
*
Yes
No
I authorize my veterinarian(s) to release any and all records pertaining to all present and past pets to Animal House Rescue and their representatives.
*
Yes
No
Signature
*
My signature authorizes my vet clinic to release any and all records pertaining to my animals to Animal HouseResuce
Submit
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