Canine Adoption Application

Pet ownership is a serious commitment that the entire household needs to consider and agree to before the animal is adopted. We want to ensure that each adoptive household is aware of, and willing and able to accept, the physical and financial responsibilities of pet ownership. Not everyone who desires to own a pet is ready to properly care for one. This questionnaire will assist both you and us in determining if your household is prepared to assume the role of responsible caretaker for a rescued animal. Thank you for taking the time to fill out this application.

Please allow our volunteers time to carefully review and process all applications (this can take several days and we will contact you once a decision has been made). If your application is received on a weekend or holiday, it may take longer for us to reach your veterinarian. We typically do not respond until we've had a chance to speak to all of your references. Thank you so much for considering a rescue!

(Fields with a red asterisk are required.)

Applicant info

Is there a particular dog of ours that you are interested in? If so, provide name and description:

Applicant's First Name *

Applicant's Last Name *

Occupation *

Including yourself, how many people live in your household? *

Please list the ages & relationship of those who live in your home.

Street Address *

City *

State *

Apartment Number (if applicable)

Zip Code *

Home Phone Number *

Work Telephone Number

Mobile Phone Number

Email Address *

Environment info

Does anyone in your household have allergies to animals? *

If yes, to what kind(s) of animals?

Does your entire household know that you are considering adopting a pet? *

If no, why not?

Household setting *

Do you live in a:

If "Other" please explain

Do you own or rent your home? If other, please explain below. *

If "Other" please explain

If you rent, does your landlord and lease allow pets?

If you rent, you MUST provide proof of permission to have a dog on the premises. Please provide your landlord's name and telephone number.

Will this pet be predominantly living inside, outside, or both? *

Where would the dog stay when you are not home? (Select as many as apply.) *

If "Other" please describe

Describe your yard (example: fenced, kennel run, other) *

Do you have a completely fenced-in yard? If so, what kind of fence? *

If fenced, what is the approximate height and area?

Are fence gates always securely latched and/or locked?

If the dog is outside other than for supervised activities, please describe what shelter would be available (examples: doghouse, shed, covered area (porch, etc.), shade trees, etc.) *

On average, how many hours per day will your pet be left alone? *

Please check the main reason you plan to adopt a pet: *

If you answered "Other" above, please explain here:

If other, please describe

Describe your home’s activity level (please select all that apply) *

Do you have a swimming pool? *

Is your pool above-ground or in-ground?

Is your pool separately fenced?

Adoption preferences

Gender *

Age range (select all that apply) *

Other preference(s)

Animals can be expensive to care for (~$1,200 - $2,800/year/dog). Are you able to provide adequate food, shelter, and medical care for the adopted dog? *

What problem(s) would make you return a dog? (Please select all that apply.) *

If "Other", please describe:

Would you be committed to work with the dog to correct any of these and most other problems? *

If so, what method of training/correction method(s) do you anticipate using? *

Problem resolution

Have you or anyone in your household ever taken a pet to Animal Control or to a shelter? *

If yes, please describe the circumstance?

To help resolve problems, are you willing to (please select all that apply)

Would you return the dog due to any of the following circumstances (please select all that apply) *

Current & Past Pets

Do you feel that a pet should be spayed/neutered? *

If "No," why not?

Please list all animals that you presently own, by name. Listing type of animal (dog, cat, other), breed, how long you have owned the animal, animal’s name, age, gender, whether the animal is spayed/neutered, and whether the animal is up-to-date on vaccines: *

Who is responsible for the daily care of the above? *

Who is responsible for care when you are on vacation? *

Please list the names of pets you owned previously (last 5 yrs) and describe what happened to them. Include name & telephone number of the veterinarian who cared for each pet. (Type 'n/a' if this is your first pet) *

Veterinarian info

Name and telephone number of current veterinarian, if any: *

If less than two years, name and telephone number of previous veterinarian:

References

Please list names, email addresses, and phone numbers for three personal references, other than relatives. If you’ve had pets, include references who know the pets you have or have had, and the care that you provide for your pets:

Reference 1 (phone # and/or email address; other than a relative) *

Reference 2 (phone # and/or email address; other than a relative)) *

Reference 3 (phone # and/or email address; other than a relative)) *

Closing questions

I consent to a representative from FCHS calling my personal and veterinarian references. *

Have you ever been charged or convicted of animal cruelty, neglect, or abandonment? *

Individuals who adopt a Floyd County Humane Society (FCHS) dog are contacted periodically for an update to help ensure that the dog successfully adjusts to its new life. If you adopt an FCHS animal, do you consent to home visits before and/or after adoption? *

Please let us know where you first heard about this dog (Petfinder, Facebook, etc.). *

Provide further information here.

If at any time an adopter cannot keep the dog, it must be returned to the Floyd County Humane Society. If the dog is not spayed or neutered at adoption, the adopter is required to alter the dog and provide a veterinary certification of altering to the Floyd County Humane Society by the date specified in the adoption contract. Dogs unaltered by the contractual date may be seized. Applicants may be subject to a background check. By signing below, I acknowledge that I have completely read this questionnaire and comprehend it fully. I know that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application or the adoption contract can result in the forfeiture of any Floyd County Humane Society animal adopted by me.

Please Initial Here & Date *