Name of Animal interested in Adopting?
First and Last Name:
Address Line 2
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?)
(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 years3 to 5 years5 or more years
Number of adults in the home:
Number of children in the home and ages:
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 on heartworm prevention? Which brand and where do you purchase it?
If no, please explain as it is a requirement for approved adoption applications: (Type N/A if not applicable.)
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.)
Where will your pet stay during the day?
Where will your pet stay at night?
Why do you wish to adopt this type of animal?
CompanionAs a gift for someoneOther
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.