RCHS Dog Adoption Application
Sign in to Google to save your progress. Learn more
Personal Information
Please tell us about yourself below
Your Name *
Spouse's / Roommates Name
Home/Cell Phone *
Work Phone
Best time to call
Email Address *
Street Address *
City, State & ZIP *
Your Age *
Select your current housing arrangement *
If you answered 'Other', please describe your current housing arrangement
Do you rent? *
If you rent, please provide your landlord's name and phone number
Do you have a fully fenced yard? *
If you do not have a fully fenced yard, this may be a factor we consider for adoptions of some dogs but it will not disqualify you from being considered to adopt any of our dogs.
Does your apartment/housing allow pets? *
Who is your employer?
Are you a student? *
Your Family
Tell us about the environment your future dog will be living in
How many adults live in your household? *
How many children live in your household? *
If you have children, please list their ages. *
If you do not have children in your household, please put N/A in the box.
Are there plans for future children, step-children, or grandchildren? *
If you answered 'Yes', please give more information on who the new children will be
Are all members of your household aware of the plans to adopt a dog? *
Do you foresee moving within the next six months? *
If you are moving, please tell us where you are moving to
If you are moving, what are your plans for your pet(s)?
Past and Current Pets
Please tell us about your prior experience with pets, especially dogs
Will this be your first dog? *
If this will be your first dog, please explain your prior experience with dogs
Please list all pets currently living in your home. *
Include type of animal, age, sex, intact?, declawed?, live indoors/outdoors? and how long you have owned them.
Please provide the name(s) and phone number(s) of your present and past veterinarians as well as those of any roommates.  Please also include the name of the owner of each animal (the account holder at the vet's office). Please be sure to speak with the veterinarian's office to give them permission to speak with a RCHS representative.   *
If you have no pets at this time, have you owned pets in the past 10 years?
Clear selection
If you answered 'Yes', please indicate what happened to your previous pet(s)
Have you ever had to put an animal to sleep for reasons other than injury or illness? *
If you answered 'Yes', please explain why you had to put the animal to sleep
Your Future Dog
Name of Animal to be Adopted *
Are you adopting this dog primarily for protection? *
Why do you want to adopt a dog? *
Why do think this particular dog is the right one for you? *
Do you have any questions or concerns about this particular dog? *
Will this dog be a companion for a child or a handicapped or elderly person? *
If you answered 'Yes', please explain how you would like this dog to act as a companion
Where will your new dog mainly be kept? *
How long will your dog be alone during a 24 hour period? *
Where will your dog spend time alone?
Will you be practicing crate training in your home? *
Have you ever house-trained a dog? *
Where will the dog sleep? *
Where will your dog eat? *
How will you exercise your new dog? *
What kind/brand of food do you plan on feeding your pet? *
What monthly heartworm preventative are you planning on using? *
Provide the brand name or answer none if you do not plan on using one.
What monthly flea/tick preventative are you planning on using? *
Provide the brand name or answer none if you do not plan on using one.
Do you have questions about dog training or behavior?
The vet bills for a dog have the potential to cost hundreds of dollars, particularly in the event of an emergency. Are you prepared to finance that kind of situation? *
It may take several weeks for your adopted dog to adjust to your home. How much time are you willing to allow for the adjustment period? *
If you answered 'Other', please indicate an adjustment period
References
Please list three references. Include their name, phone number and relationship to you. Only one relative (who does not live with the applicant) is permitted.
Reference 1 *
Reference 2 *
Reference 3 *
Other Information
Please include any additional information that you would like us to take into consideration while evaluating your application
By adopting a dog in the care of RCHS, you will agree to the following terms.
I agree to keep an ID on the adopted animal at all times, whether inside or outside of the house, and to obtain all of the necessary licenses required by local authorities.

I agree to provide the adopted pet with necessary inoculations/heartworm treatments at the intervals advised by my veterinarian.

I agree to have the adopted pet under my control when it is not on the confines of my property. If the adopted pet is a cat, I agree to keep the cat as an indoor- only pet. The adopted pet will not be tied or chained. I agree to provide nutritious food and a continuous supply of clean water.

If the adopted pet is a cat, I agree NOT to have it declawed; understanding that declawing is a painful amputation of the terminal bone at the joint, and would be mutilation of the cat's paws.

If, for any reason, I cannot keep the adopted pet, I agree to notify the Riley County Humane Society (RCHS) at the above address and phone number, and return the adopted animal to an active member of the organization.

I understand that any failure to perform the foregoing agreement will constitute a breach of contract. In the event of a breach in contract, I authorize the Riley County Humane Society to reclaim both possession and ownership of the pet.

I understand that the pet covered by these adoption papers, is, as far as can be determined by the RCHS, in good health, and that the RCHS is not responsible for any medical fees incurred after the adoption date. However, if a health problem develops during the first 10 days, I should notify the RCHS to discuss the matter.

I agree to provide requested feedback in the adoption follow-up program, and I give the RCHS visitation rights to ensure that the terms of this adoption agreement are being observed.
Do you agree to the above provisions? *
You should be redirected to a confirmation page after hitting the submit button.  For mobile users, if nothing seems to happen then a required field may be empty.  The field will have red text near it that states 'This is a required question'
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of rchsks.org.

Does this form look suspicious? Report

Google Forms