Second Chance Adoption Application
First & Last Name *
Example: Scott Faust
Full Address *
Example: 123 First St. Mansfield, PA 16933
Best Contact Number *
Example: 570-123-4567
Secondary Contact Number
Example: 570-123-4567
Email Address
Name of pet or describe the type of pet you are interested in: *
Example: I'm interested in a short haired cat that is young. -OR- I'm interested in adopting Scruffy.
Why do you want to adopt a pet? *
What do you think are the most important responsibilities in having a pet? *
All pets currently with you: Name, Age, Type, Spayed/Neutered?
Example: Bailey, 10, Beagle, Neutered (then hit ENTER) add more, HIT ENTER after each pet
Pets previously with you: Name, Type, Spay/Neuter, Reason for no longer having?
Example: Fido, Dog, Spayed, Passed Away (then hit ENTER) add more, HIT ENTER after each pet
Veterinarian Name
Veterinarian Phone Number
If other than your name, what name would your pet files be under?
People living in or visiting the house frequently: Name, Relationship, Age *
Example: Logan, Son, 14 (ENTER) Jamie, Wife, 40 (ENTER) Will, Neighbor/pet sitter, 38
Does anyone in your household have pet allergies?
Clear selection
Do you own or rent your house?
Clear selection
If you rent, please provide the name and number of your landlord
Example: John Doe, 570-123-4567
Do you have a fenced yard?
Clear selection
Where will the pet be kept during the day? *
Where will the pet be kept during the night? *
How many hours per day will your new pet be alone? *
When gone more than 8 hours, what plan will you have for your pet’s care? *
Having a pet involves many financial expenses such as food, flea and tick medicines, vaccinations, veterinary visits, and emergency costs. Are you able and prepared to meet these needs for the health and wellbeing of your new family member? *
Reference #1 (may be related to you) Name, Relationship, Phone *
Example: George Lucas, Father, 570-564-3452
Reference #2 (not related to you) Name, Relationship, Phone *
Example: George Lucas, Father, 570-564-3452
Reference #3 (not related to you) Name, Relationship, Phone *
Example: George Lucas, Father, 570-564-3452
By submitting this form, I represent that the information that I have provided is truthful to the best of my knowledge and belief. *
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