Dog/Puppy Adoption Application
This online form asks all the relevant questions to be approved to adopt a Dog or Puppy from Heartland Humane Society
By clicking Yes below, I acknowledge "Our purpose at Heartland Humane Society is to place an animal in a good and responsible home where it will receive proper care, love and supervision for life so that it does not ever become a stray again. This application is to assist us in the careful selection of home placement for pets we have available to adopt. You must be 18 years or older to adopt. We check publicly available criminal record information through Iowa Courts Online as part of our approval process. We reserve the right to refuse any pet adoption." *
Name of Dog/Puppy you wish to adopt *
Your answer
Date
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Full Name (First, Middle, Last) *
Your answer
Date of Birth *
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Full Name of Spouse/Partner/Roommate
Your answer
Date of Birth Spouse/Partner/Roommate
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Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Primary Phone *
Your answer
Work Phone
Your answer
Occupation
Your answer
Email
Your answer
Why do you want to adopt? *
Have you ever adopted from a shelter before? *
If so, when & where?
Your answer
Have you ever been refused adoption from a shelter/rescue before? *
Personal Reference - Name *
Your answer
Personal Reference - Relationship *
Your answer
Personal Reference - Phone # *
Your answer
Your veterinarian (if you have one)
Your answer
Veterinarian - Clinic or Office
Your answer
Veterinarian - Phone Number
Your answer
When was the last visit to your vet?
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Reason for the visit
Your answer
Can you commit to care for a dog you adopt for its whole life (preventative medication may cost $150-200 each year, food and pet supplies may cost $100+ each year)? *
Where do you live? *
If "Mobile Home", do you rent your lot?
Do you own or rent? *
Landowner/Landlord - Name (if not you)
Your answer
Landowner/Landlord - Phone Number
Your answer
How many adults are in the home? *
Your answer
Do you have children? *
Children's ages
Your answer
Do you have children that visit frequently? *
What portion of your property is fenced? *
Your answer
If fenced, what type and how high?
Your answer
If you do not have a secure, fenced-in yard, how do you plan to exercise your dog? (HHS DOES NOT ADOPT to anyone whose intentions are to keep their dog chained to a stake, dog house, or tree) *
Your answer
Who will be responsible for feeding the dog you adopt? *
Your answer
Will your new dog be kept inside or outside (or both)? *
If your dog is to be an outside animal, what year-round shelter is provided for its protection?
Have you ever owned a dog before?
Have you ever bred animals?
List all pets currently in the home and within the past 5 years. Name, Breed, Age, Fixed?, Vaccinated?, Still Own?
Your answer
Does anyone in your household have allergies? *
If so, what are they allergic to?
Your answer
If you move in the future, what will you do with the pet you’re adopting and your other pets? *
Your answer
A representative of HHS may make a follow-up visit to see how the dog you have adopted is settling into their new home. What would be a convenient time to stop by? *
Your answer
How many hours will the animal be alone in the home without human companionship during the day? *
Your answer
How many hours will the animal be alone in the home without human companionship at night? *
Your answer
How many days a week will the animal be alone without human companionship? *
Your answer
Do you travel for work? *
Where will the dog be kept when you're out of town?
Your answer
Do you plan to use a chain, rope or cable as the only means of keeping the dog confined? *
Do you understand that state laws may require vaccinating, leashing and licensing dogs? *
Have you ever had an issue with the animal control department or local law enforcement involving your animal(s)? *
Do you plan to housetrain the dog? *
If so, how do you plan to do so?
Your answer
Dogs will bark, run, chew and play. How will you handle this? *
Your answer
It may take me two weeks to adjust to my new home, or longer if other pets are there. Are you willing to give me this much time to adjust? *
By clicking Yes below, I certify that the information is true and that I will recognize that any misrepresentation of facts may result in me losing the privilege of adoption or keeping an adopted pet. I understand that HHS has the right to deny my request to adopt an animal and I authorize investigation of all statements in this application. I understand that this application is the property of HHS. It is Iowa law that all animals adopted from a humane shelter must be spayed or neutered. Furthermore, HHS only adopts to homes where all the current pets are spayed or neutered. We reserve the right to refuse adoption to anyone for any reason, and failure to comply with specifications in this agreement constitutes just cause for HHS to revoke the adoption arrangement by removing the animal from your ownership and care, resulting with full ownership of the pet reverting back to HHS. *
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