Washburn County Area Humane Society

PRE-ADOPTION FORM

FIRST NAME:                       
MIDDLE INITIAL:                   
LAST NAME:                        
DATE OF BIRTH:                    
IS THERE A SPECIFIC ANIMAL YOU ARE INTERESTED IN?:      
EMAIL ADDRESS:                    
HOME PHONE NUMBER:                
CELL PHONE NUMBER:                
ADDRESS:                          
LENGTH OF TIME YOU HAVE LIVED AT THIS ADDRESS:         
P.O. BOX:                          
CITY:                             
COUNTY:                           
STATE:                            
ZIP CODE:                         
PREVIOUS ADDRESS IF LESS THAN 5 YEARS:                  
EMPLOYER:                         
WORK PHONE NUMBER:                
IF YOU ARE UNEMPLOYED, WHAT IS YOUR SOURCE OF INCOME:       
IF YOU ARE SELF-EMPLOYED, PLEASE STATE TYPE OF BUSINESS:   
SPOUSE/PARTNERS EMPLOYER:         
S/P WORK PHONE:                    
DAYTIME PHONE WHERE YOU CAN BE REACHED:                    

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YOU LIVE IN A:                    
DO YOU OWN YOUR OWN HOME?:        
IF YOU RENT OR LIVE IN A MOBILE HOME PARK, PLEASE GIVE US YOUR LANDLORDS NAME AND PHONE NUMBER:      

LIST THE NAMES AND AGES OF ALL ADULTS LIVING IN HOUSEHOLD:                                          

LIST THE NAMES AND AGES OF ALL CHILDREN LIVING IN HOUSEHOLD - IF NO CHILDREN PLEASE STATE NONE:     

PLEASE LIST ALL ANIMALS THAT CURRENTLY LIVE IN YOUR HOUSEHOLD.  PLEASE INCLUDE ANIMALS NAME, AGE, TYPE OF ANIMAL AND SEX - IF NO CURRENT PETS, STATE NONE.:     

ARE THESE ANIMALS SPAYED OR NEUTERED?:         

PLEASE LIST PETS NAMES AND BREED OF ANY OTHER ANIMALS OWNED IN THE PAST THREE YEARS THAT ARE NO LONGER WITH YOU - IF NO PAST PETS, STATE NONE:           

WHICH VETERINARIAN/CLINIC HAVE YOU USED OVER THE PAST 5 YEARS?  IF YOU HAVE NOT USED A VET, PLEASE STATE NONE:           
CLINICS ADDRESS - STATE NONE IF YOU HAVE NOT USED A VET.:     

CLINICS PHONE NUMBER - STATE NONE IF YOU HAVE NOT USED A VET.:

ARE THE ANIMALS YOU CURRENTLY OWN UP TO DATE ON THEIR VACCINATIONS?:     

IF NOT, PLEASE EXPLAIN:                         

HAVE YOU ADOPTED A PET FROM A HUMANE SOCIETY OR RESCUE?:                 

IF YES, NAME OF THE FACILITY:                  

DOES ANY MEMBER OF YOUR HOUSEHOLD HAVE ALLERGIES TO ANIMALS?:             

HAVE YOU OR ANY MEMBER OF THE HOUSEHOLD BEEN CONVICTED OF CRIMES AGAINST ANIMALS?:       

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DO YOU TRAVEL A LOT?: 
IF YES, WHO WILL CARE FOR YOUR PETS WHEN YOU ARE AWAY?:      

WHO WOULD CARE FOR YOUR PETS IF AN EMERGENCY ARISES AND YOU NEED TO BE AWAY?:   

IF YOU HAD TO MOVE IN THE FUTURE, WHAT WOULD YOU DO WITH YOUR PETS?:       

IT MAY TAKE YOUR PET TWO WEEKS OR LONGER TO ADJUST TO ITS NEW HOME. ARE YOU PREPARED TO ALLOW FOR THIS ADJUSTMENT PERIOD?:     

ARE YOU FAMILIAR WITH THE PET LAWS IN YOUR AREA?:          

HAVE YOU CONSIDERED THE EXPENSE OF PROVIDING FOOD, LICENSE, VACCINATIONS AND MEDICAL CARE FOR THE PETS YOU ARE ADOPTING?:       

DO YOU FEEL IT IS IMPORTANT TO SPAY/NEUTER YOUR PET?:        
IF NO, WHY NOT?:        

PLEASE TELL US WHY YOU WOULD LIKE TO ADOPT AN ANIMAL FROM US. CHECK ALL THAT APPLY:

FRIEND/COMPANION

COMPANION FOR ANOTHER PET

GIFT

WATCHDOG

FOR A CHILD

TO BREED

FOR HUNTING

AS A MOUSER

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DOGS CAN LIVE 15 YEARS OR LONGER.  ARE YOU PREPARED TO TAKE RESPONSIBILITY FOR THE DOGS ENTIRE LIFE?: 

ARE YOU FAMILIAR WITH THE TRAITS AND NEEDS OF THE DOG/BREED YOU ARE CONSIDERING?:    

HOW WOULD YOU CORRECT POSSIBLE PROBLEMS SUCH AS -
BARKING:                
FENCE JUMPING:          

CHEWING:                
DIGGING:                
HOUSE SOILING:          

IF ADOPTING A PUPPY, HOW DO YOU INTEND TO HOUSETRAIN HIM/HER?:     

DO YOU PLAN TO TAKE YOUR DOG TO OBEDIENCE CLASSES:                
II PLAN TO KEEP THIS DOG AT:                                      
WHERE WILL THE DOG BE KEPT DURING THE DAY?:                    
AT NIGHT?:                                                        
WHERE WILL THE DOG BE KEPT WHEN LEFT ALONE?:                      
WHEN OUTDOORS, HOW WILL THIS DOG BE CONFINED?
WHEN OUTDOORS, WHAT TYPE OF SHELTER WILL BE AVAILABLE?:           
DO YOU PLAN TO LICENSE YOUR DOG?:                                 
WHAT TYPE OF ID WILL YOUR DOG WEAR?:                              

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DO YOU PLAN TO LET YOUR CAT OUTDOORS?:                             
WHERE WILL YOUR CAT BE KEPT DURING THE DAY?:                       
AT NIGHT?:                                                         
WHAT TYPE OF ID WILL YOUR CAT WEAR?:                               
ARE YOU FAMILIAR WITH COMMON CAT BEHAVIORS SUCH AS: JUMPING ON COUNTERS/FURNITURE, CHEWING ON PLANTS OR SCRATCHING?: 

ARE ANY OF THESE BEHAVIORS MENTIONED A CONCERN FOR YOU?:           
PLEASE COMMENT:                                                    
DO YOU INTEND TO DE-CLAW?:                                          
IF YES, DO YOU UNDERSTAND THE PROCEDURE INVOLVED WHEN DE-CLAWING?:   
IF YES, VERY BRIEFLY EXPLAIN WHAT IS DONE IN A DE-CLAW PROCEDURE:   
ARE YOU INTERESTED IN INFORMATION TO ALTERNATIVES TO DE-CLAWING?:    
ARE YOU FAMILIAR WITH THE TRAITS OF BREED AND NEEDS OF THE CAT YOU ARE CONSIDERING?:    


CATS LIVE LONGER THAN 15 YEARS.  ARE YOU PREPARED TO TAKE RESPONSIBILITY FOR THE CATS ENTIRE LIFE?: 

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ADOPTER:                    
TODAY’S DATE:                
SPOUSE OR PARTNER: