Please list all the dogs you are interested in adopting. If open to best fit, please put "general application" *
Please list other shelters or rescue organizations have you submitted an adoption application in the past two weeks? *
You must be aged 18 or older to fill out this application. Are you 18 or older? * Yes No
Are you filling out this application for someone else? * Yes No
If you are filling out this application for someone else, please list who will be the pet owner:
Your Previous Names Used Within Past EIGHT years:
Your Age *
Your Email *
If under age 21, please provide parent/guardian name and phone number:
Best Time/Method to contact you and/or your co-applicant? *
Employment Status * Employed Full Time Employed Part Time Retired Unemployed Social Security Disability Student Other
Name of Employer *
Please list any other source of income
Email
Housing – I live in a (select below) – Please note, the dog you are applying for may not be approved for apartments or mobile homes – please check the dog description! * House Apartment Condo Mobile Home Duplex Other
If "other" please explain:
Rent or Own – please note, some rentals, condos, or home owners associations have restrictions on dog breeds or dog sizes! * Own Rent Live with Parent
Length of Time at Residence *
If you rent, you must provide your landlord's name, phone number, and the name of the apartment complex or mobile home park:
If invisible fence, is it currently installed and activated? * Yes No
Approximate size of fully fenced area or kennel space: *
If physically fenced-in yard, is it fully enclosed to all parts or the house/garage? * Yes No
How best describes the primary pet caregiver? * Retired Stay at home parent Employed full time Employed part time College student Child
List names (first and last) and ages of ALL adults and children living full or part time in your home *
Do you or anyone in your household suffer from pet allergies? * Yes No
If yes, please explain
Is everyone in the household in agreement with adopting a new friend? * Yes No
If not, please explain why:
Do you foresee any changes in your living arrangement within the next six months to one year? (moving, vacation, live-in visitors, new baby, new pets, etc.) * Yes No
If yes, please describe:
Have you ever adopted an animal from HSSCM? * Yes No
If yes, please list animal name(s) and dates:
Have you ever surrendered an animal to HSSCM or any other rescue, shelter, or animal control facility? * Yes No
If yes, please explain:
Have you ever given away a pet? * Yes No
If yes, please describe situation and provide contact information for where the pet is currently:
Have you ever fostered for an animal agency or friend with the intent to adopt, or did a temporary adoption which did not work out? * Yes No
If yes, please explain:
If pet is a gift, or "other" listed above, please explain:
Have you ever personally owned a dog for which you were either primarily or jointly financially responsible for the dog's vet care and all other daily care needs? * Yes No
What kind of dogs have you had exposure to? Please list breeds and how long it has been since you were around these dogs: *
Please list ALL pets currently in the home by species, age, spayed/neutered, inside/outside, etc.) *
Please list ALL animals no longer living with you that you have had within the past EIGHT YEARS including name of pet, breed, age, how long you owned the animal, and date of death or reason pet is no longer living with you: *
If you travel, who will care for your pets? *
Do you want a puppy, adult, senior dog? What is the age range of the dog you are looking to adopt? *
What gender are you looking for * Male Only Female Only Open to Best Fit
Are you looking for a specific breed of dog? * Yes No
If specific breed, what knowledge do you have of that breed?
Would you consider a special needs dog (physically handicapped, extremely shy, etc.)? * Yes Not at this time Maybe if it's the right fit
List any other characteristics you want in your new dog:
Please list any other unwanted behaviors:
Are you prepared for a 10-15+ year commitment to a dog, and would you still be able to care for this dog if your home or family situation changed? * Yes No
Who will take care of your dog in case of your illness and/or death? *
How will your dog be exercised? *
How many hours per day will your dog be left alone? *
Where will your dog be kept? * Inside Only Indoor/Outdoor as the dog desires Outside
Will the dog be restricted to a certain area or crated? If yes, please explain: *
Have you ever gone through obedience training with a previous dog? Yes No
Are you interested in more information on different training methods and how to acclimate your new dog to your home, or do you prefer to do it on your own? * I'm interested in information sheets! I'm interested in training classes through HSSCM! I can do it on my own!
Will the dog be living at the address you provided? * Yes No Other
If "no" or "other" please explain:
Please list ALL veterinary clinics (name, location, phone number) you have used for the past EIGHT years, and if your current or previous pets might be under another name than your current first and last name. Please note, many veterinarians require prior authorization for HSSCM to request veterinary references. You may need to call your vet to provide authorization. *
Do you use flea/tick preventative? * Yes No
Brand/Frequency:
Do you use heartworm preventative? * Yes No
List brand and whether seasonal or year-round: *
Do you understand how dogs get heartworm disease? * Yes No, I need more information
Are your current pets in your home up to date of vaccinations? * Yes No
If not, please explain:
Are your current animals licensed and micro-chipped? * Yes No
If no, please explain:
Are you interested in having the current pets in your home microchipped? Yes No
Submitting an application for adoption constitutes agreement to HSSCM verifying your current pets' or past pets' reproductive status and health with the veterinary clinics listed on this form. Do you acknowledge this requirement? * Yes No
Please list the first name, last name, phone number and relationship of a non-relative reference who does NOT live in your home. *
Please list the first name, last name, phone number and relationship of a non-relative reference who does NOT live in your home. *
Please provide any additional information you feel would be helpful in processing your application:
Please type your name and date below to have your application signed digitally. By typing your name below, you understand that this application is the property of HSSCM. HSSCM is a private entity and not affiliated with any other humane society, shelter or rescue. Your information will not be used for anything other than processing your application for adoption. This information will be documented in our secure database and not shared with any third-party agencies. You are not obligated to adopt from HSSCM, nor does it obligate HSSCM to adopt to you. You are verifying all information provided is true to the best of your knowledge. Falsifying information will result in nullifying your application. *