CANINE ADOPTION APPLICATION
Humane Society of the Delta
P O Box 3218
West Helena AR 72390
(870) 753-2119
info@humanesocietyofthedelta.org
Email address *
PLEASE FILL THIS OUT COMPLETELY SO THAT WE MAY PROCESS YOUR APPLICATION
It takes a lot of time and effort for our volunteers to process applications. PLEASE DO NOT APPLY TO ADOPT UNLESS YOU ARE REALLY GOING TO ADOPT A DOG, AND YOU HAVE ALREADY DISCUSSED WITH YOUR FAMILY AND CAN PICK UP THE ANIMAL AS SOON AS IT'S AVAILABLE. WE CANNOT "HOLD" ANIMALS FOR PEOPLE. Please verify that you've read this.
Date *
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Name of the pet(s) you would like to adopt *
Your answer
Adopter's Name (First and Last) *
Your answer
List ALL adults who live with you (First and Last Name)
Your answer
Address: Street *
Your answer
City, State, Zip *
Your answer
Home Phone
Your answer
Cell Phone *
Your answer
Email address (Please only use one email for all correspondence with us) *
Your answer
Age *
If you live in your parent's house, please provide their name and number.
Your answer
Home Ownership Status *
Residence Type *
If you rent, please provide your landlord's name and phone number
Your answer
Is there extra security deposit for pets? If so how much?
Your answer
Whom do you live with? Please check any that live with you. *
Required
Number of children and ages
Your answer
Are any family member allergic to pets? *
If anyone if your household is allergic to pets, please explain who is allergic and what is the allergy to?
Your answer
Employed *
Place of Employment: Address, City, State, Work Phone, Position and length of Employment *
Your answer
Will the animal live with you? *
Your answer
Current Pets: Please list Name, Type of Animal, and Age
Your answer
Former Pets: Please list Name, Type, Breed, Age, What happened to them, and Year
Your answer
Will this be your first dog or puppy? (Only answer if you didn't list a current or former dog above)
If this is your first dog, do you have any prior experience with dogs? Could you tell us what experience you have. (It's ok if you don't have any experience, we just would offer more support at adoption for newbies.)
Your answer
Have you ever surrendered an animal? If so, what was the situation? *
Your answer
Have you ever adopted animal from us?
Reason for wanting animal *
Required
Where will this dog spend the Day? *
Required
How many hours a day will the dog or puppy be alone? *
Where will the dog or puppy spend the night? *
Required
How do you plan to keep this pet to on your property outside? *
Your answer
Who will have primary care of this dog? *
Your answer
Who will care for this dog when you leave for vacation? *
Your answer
Have you ever house trained a dog or puppy before? *
Name and phone number of current or former veterinarian . (A veterinarian's reference is the fastest way to get an approval, please call them immediately and give them permission to speak to us.) *
Your answer
What person's name will your pet's vet records be listed under? (First name, last name, don't forget maiden name if you pet is still listed under that)
Your answer
Even if your pet passed away 5-6 years ago, most veterinarians still have your records and this the fastest way to get an approval. Please call them as soon as possible to give them permission to speak to a representative of the Humane Society. If we call your veterinarian and they haven't been given permission to speak to us, we will have to move on to the next application. *
If you currently have a pet, is it current on all vaccinations? *
If you currently have a dog, are you using a heart worm preventative? *
What kind of heart worm prevention do you currently use?
Your answer
If you don't use a veterinarian currently, please submit THREE non-family references. (FULL Name, phone number, relation) (Write N/A if you provided a vet reference) An application without a veterinarian reference MUST have 3 references. *
Your answer
Are you aware of the current related laws that pertain to owning a pet where you reside? *
Adopting a puppy or dog can be a lot of work, especially at first. There could be some sleepless nights, messes in the house, you might need to "puppy proof" your house so things don't get chewed on etc. You won't be able to take off for the weekend spur of the moment without first making plans for your new pet. It is like having a child, but the roughest part doesn't last nearly as long as it does with human babies. : )
Often times pets coming from a shelter environment will require continued medical care to treat and/or prevent intestinal parasites. Are you prepared to provide this needed care for an adopted pet? *
Puppies under the age of four months require a series of three to four vaccines before being considered fully immunized. Adult pets will require yearly booster vaccines. Are you prepared to provide this needed care for an adopted dog? *
Dogs and puppies who are in shelters have a higher risk of exposure to illnesses due to the amount of animals the are potentially exposed to. The Humane Society of the Delta makes every effort possible to ensure the health and well being of it’s adoptable pets. Once in a while, despite best efforts, a pet will become ill post adoptions. Pet insurance is provided that typically helps cover the cost of minor health issues. Adopters are responsible for the deductible and signing up for this insurance offer after adoption. If a life threatening illness occurs within two weeks of adoption, The Humane Society of the Delta will take back the pet and treat him or her at our partner veterinarian. As a not for profit organization, all bills you incur at you private veterinary clinic will not be repaid. Do you understand the health and treatment policies of The Humane Society of the Delta ? *
Application must be completed in its entirety. If you leave any items incomplete, your application will be denied. Please help us speed up the adoption process and ensure all items are complete before you submit this application. Many factors go into determining which applicant will be matched with a particular animal. If you are not chosen for this pet, it does not mean that you are not considered a good pet owner or that you home is not acceptable. Our goal is to place every animal in a home that will best suit its needs.I hereby swear that the answers given to me on this application are true and complete to the best of my knowledge and I understand the application process. I also understand that regardless of approval status, The Humane Society of the Delta is not obligated to adopt a pet to me. *
Any questions regarding an animal you are interested in, or your application should be sent to adoptionshsdelta@gmail.com. Please DO NOT call the shelter as they are busy on rescue calls and taking care of the animals. If you want someone to call you, email us with your phone number and we will call you back when we can. *
Signature (type name), Date *
Your answer
BEFORE YOU HIT SUBMIT, REVIEW YOUR APPLICATION. Did us you give us accurate information as to your vet's name and number? If you didn't have a veterinarian as a reference, did you provide three non-family references and their numbers? Did you write your COMPLETE address City, State and Zip? If you did NOT, your application will be processed LAST. We are all volunteers with jobs and families and do not have time to ask hundreds of people for information that was already asked for in this application. *
Your answer
Please add any comments you would like to make here that will help us make a good decision for you and your new companion.
Your answer
A copy of your responses will be emailed to the address you provided.
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