Application

Adoption Application

This questionnaire must be completed by anyone interested in adopting a pet from the Henry County Humane Society-Geneseo. We at the HCHS-G try to place our animals into permanent, responsible homes while matching the pet to you and your lifestyle. NOTE: THE PROVIDING OF FALSE INFORMATION HEREIN WILL RESULT IN THE FORFEITURE OF ADOPTION FEES AND ANY ANIMALS ADOPTED. We reserve the right to refuse an adoption based on poor or incomplete vet history.

* Indicates required field

Name of Applicant *

Email *

Home Phone *

Cell Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How long have you lived at this address? *

What kind of pet are you looking for? *

Is there a specific pet you are interested in? *

Who are you adopting for? *

Are you 18 years of age or older? *

Yes No

Are you currently employed? *

Yes No

If no, is someone else in the household employed? *

Yes No

Why are you adopting a pet? (Family pet, companion animal, etc.) *

Do you own your own home? *

Yes No

If no, does your lease allow pets? *

Yes No

Landlord's Name: *

Landlord's Phone: *

Who lives in your home? (List all names and ages of children) *

Do all members of the household know that you plan to adopt a pet? *

Yes No

Does anyone in your household have any allergies? *

Will an adult be home during the day? *

Who will be responsible for taking care of your pet? *

If you are adopting a dog or puppy:

What procedures will you use for housebreaking? *

How will you handle chewing or destructive behavior? *

If adopting a cat or kitten:

How will you handle scratching or destructive behavior? *

Have you ever adopted from the Henry County Humane Society - Geneseo or another shelter? *

Yes No

If yes, which shelter and where is that pet now? *

List any pets you've had in the last 5 years and where they are now: *

Have you ever turned an animal in the the Henry County Humane Society - Geneseo or another shelter? *

Yes No

If yes, under what circumstances? *

Have you ever had to give up one of your own pets? *

Yes No

If yes, under what circumstances? *

Has a dog died on your premises of distemper? parvo, or unknown causes in the last three months? *

Yes No

Has a cat died on your premises of distemper, leukemia, or unknown causes in the last three months? *

Yes No

Do you currently own a pet? *

Yes No

List the animals' names, with age, sex, and breed: (Example: Sadie, 4 years, female, golden retriever) *

Do your current/past pets live indoors or outdoors? *

Are/were your current/past pets' shots up to date? *

Yes No

If no, please explain: *

Are/were your current/past pets spayed or neutered? *

Yes No

If no, please explain: *

Are/were your dogs on heartworm preventative? *

Yes No

If yes, which brand/product? *

If yes, where did you purchase the heartworm preventative? *

Most recent vet clinic used: *

List any additional vet clinics that cared for your pets and their phone numbers, as well as any other names vet records may be listed under. *

Are you willing to go to the expense and trouble of taking your new pet to the vet AT LEAST once a year and at other times when needed? *

Yes No

Will your new pet live: *

Is there yard available? *

Yes No

If yes, is the yard completely fenced? *

Yes No

Vet Clinic Phone Number *

What do you plan to do with your pet when you are on vacation? *

If you have to move, what will you do with the pet? *

Personal References

Name *

First

Last

Name *

First

Last

Phone Number *

We reserve the right to have inspections of the pet and the living conditions at any time. I authorize HCHS-G to contact the veterinarian office named above to confirm the medical records/history of my pets.

Signature *

If form does not submit, please go through the form and assure that you have completed all of the information - errors will highlight.

Submit