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Name of Animal interested in Adopting?
First and Last Name:
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Are you 21 or over?
Will an adult be home during the day?
Do you have a fenced yard?
If you have a fenced yard, is it a chain link? privacy? How tall is the fence?
Type of dwelling (Apartment, single family residence, duplex, townhome, condo, loft, etc?)
Live at Home
If you rent: Are pets allowed?
Does your landlord require a security deposit?
(proof of payment required before the adoption can be completed)
If less than one year at current residence, please provide previous address:
Length of time at previous residence?
1 to 3 years
3 to 5 years
5 or more years
Do both adults work outside the home?
Number of adults in the home:
Number of children in the home and ages:
Do you currently have other dogs or cats?
If yes, please give names, breeds and ages, as well as any other relevant information about the pet: (Type N/A if not applicable.)
Is your dog/cat current on yearly vaccinations?
Is your dog on heartworm prevention? Which brand and where do you purchase it?
If you have current pets, are they spayed/neutered?
If no, please explain as it is a requirement for approved adoption applications: (Type N/A if not applicable.)
If you don’t currently own a pet, have you owned one in the past?
If yes, please explain why the pet is no longer with you: (Type N/A if not applicable.)
Name/address/phone # for current veterinarian (To check current pet records.) or veterinarian that you plan to use (if you don’t have a current pet.)
Where will your pet stay during the day?
Where will your pet stay at night?
If you are adopting a cat/kitten are you planning to have it declawed?
If you are adopting a cat/kitten are you planning to let it go outside?
Why do you wish to adopt this type of animal?
As a gift for someone
If you selected other above, please specify:
This questionnaire must be completed by anyone interested in adopting a pet from the Henry County Humane Society (HCHS). We at HCHS try to place our animals into permanent, responsible homes, while matching the pet to you and your lifestyle. NOTE: THE PROVIDING OF FALSE INFORMATION HEREIN WILL RESULT IN THE FORFEITURE OF ADOPTION FEES AND ANY ANIMALS ADOPTED. We reserve the right to refuse an adoption based on poor or incomplete vet history. I authorize HCHS to contact the veterinarian office named above to confirm the medical records/history of my pets.
This field is for validation purposes and should be left unchanged.
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Henry County Humane Society.
All Rights Reserved.
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