Welcome - Humane Society of South Central Michigan
Canine Adoption ProfileDate: FORMTEXT ?????Time: FORMTEXT ?????Please be advised by filling out this application you are not obligated to adopt. Completing this profile is not a guarantee that you will be allowed to adopt a pet at this time. Name: FORMTEXT ?????Driver’s License: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Email: FORMTEXT ?????Phone #1: FORMTEXT ?????Phone #2: FORMTEXT ????? Your Age: FORMCHECKBOX 20 or under FORMCHECKBOX 21 – 35 FORMCHECKBOX 36 – 55 FORMCHECKBOX 56+Length of time living at address: _______________Do you: FORMCHECKBOX Own FORMCHECKBOX Rent Apartment FORMCHECKBOX Rent House FORMCHECKBOX Live with Parents FORMCHECKBOX Other: FORMTEXT ?????Do you foresee any changes in your current living arrangement (i.e. moving, house guest, vacations,?etc.)? FORMCHECKBOX NO FORMCHECKBOX YESIf YES, please explain: _________________________________________________________Landlord Name and Phone: FORMTEXT ?????Known rental restrictions/conditions: FORMCHECKBOX Weight FORMCHECKBOX Breed FORMCHECKBOX Other: FORMTEXT ?????Are you: FORMCHECKBOX Employed FORMCHECKBOX Unemployed FORMCHECKBOX Retired FORMCHECKBOX Student Name of Employer: _________________________Is anyone in your household allergic to cats or dogs? FORMCHECKBOX Yes FORMCHECKBOX No How many people live in your home? _________ Are there children in your home? FORMCHECKBOX Yes FORMCHECKBOX No Ages of Children:_______________________________Co-Applicant: FORMTEXT ?????Relationship: FORMTEXT ?????Email: FORMTEXT ?????Phone: FORMTEXT ?????Employer: FORMTEXT ?????Age: FORMCHECKBOX 20 or under FORMCHECKBOX 21 – 35 FORMCHECKBOX 36 – 55 FORMCHECKBOX 56+ FORMCHECKBOX Employed FORMCHECKBOX Unemployed FORMCHECKBOX Retired FORMCHECKBOX Student Dog Experience: FORMCHECKBOX First-time owner FORMCHECKBOX Have had one or two dogs FORMCHECKBOX Dog expert!Time Away from Home: FORMCHECKBOX Home all day FORMCHECKBOX Home part-time FORMCHECKBOX Away 7-10 hours daily FORMCHECKBOX Away longer than 10 hours FORMCHECKBOX Can bring dog to workOur Dog Will: FORMCHECKBOX Live indoors only FORMCHECKBOX Go indoors/outdoors FORMCHECKBOX Live outdoors onlyContainment: FORMCHECKBOX Fenced-in yard FORMCHECKBOX Invisible fencing FORMCHECKBOX Cable/tie out FORMCHECKBOX Leash walking FORMCHECKBOX Free roam on property FORMCHECKBOX Other: FORMTEXT ?????How much do you anticipate spending yearly to provide food and medical care for your new dog? FORMCHECKBOX Less than $200 FORMCHECKBOX $200 - $400 FORMCHECKBOX $400 - $600 FORMCHECKBOX $600+Where will your dog spend its time alone? (check all that apply) FORMCHECKBOX Inside FORMCHECKBOX Outside FORMCHECKBOX Both FORMCHECKBOX Crate FORMCHECKBOX Other: FORMTEXT ?????Home Atmosphere: FORMCHECKBOX Busy! Lots of Activity/Noise FORMCHECKBOX Moderate, some visitors FORMCHECKBOX Quiet and SereneName of current and/or previous veterinarian & phone number: FORMTEXT ?????Current Pets in HomeType of animal: _________________Name: _________________________Age: __________ FORMCHECKBOX Male FORMCHECKBOX FemaleSpayed/Neutered FORMCHECKBOX Yes FORMCHECKBOX NoKept: FORMCHECKBOX Inside FORMCHECKBOX Outside FORMCHECKBOX Both How long have you had this pet? _____Type of animal: _________________Name: _________________________Age: _________ FORMCHECKBOX Male FORMCHECKBOX FemaleSpayed/Neutered FORMCHECKBOX Yes FORMCHECKBOX NoKept: FORMCHECKBOX Inside FORMCHECKBOX Outside FORMCHECKBOX Both How long have you had this pet? _____Type of animal: _________________Name: _________________________Age: __________ FORMCHECKBOX Male FORMCHECKBOX FemaleSpayed/Neutered FORMCHECKBOX Yes FORMCHECKBOX NoKept: FORMCHECKBOX Inside FORMCHECKBOX Outside FORMCHECKBOX Both How long have you had this pet? _____Name(s) of dogs you are interested in adopting from our facility: FORMTEXT ?????Please list any additional pets that have been in your care the past eight years (include all exotic pets):Name/Type of AnimalBreedYears OwnedSpayed/ NeuteredInside/OutsideWhere is pet now? (if deceased, when?) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????If you have adopted an animal from HSSCM previously, please list the animal name and date: _____________________Have you ever had to find a new home for one of your pets, or surrender a pet to a shelter or animal control? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ?????What will you do with your dog when you go on vacation? FORMTEXT ?????If you have to move, what would you do with your dog? FORMTEXT ?????In the case of personal illness or your death, who will provide care for your dog? FORMTEXT ?????What do you think will be the hardest part of having a new dog? FORMTEXT ?????Under what circumstances would you need to return your dog to HSSCM? FORMTEXT ?????Will your dog be on heartworm prevention? FORMTEXT ?????How much time will you give your dog to adjust to your home? FORMTEXT ?????What qualities would you like in a dog? FORMTEXT ?????What qualities do you NOT want in the dog you adopt? FORMTEXT ?????How will you exercise your dog? FORMTEXT ?????How often? FORMTEXT ?????Have you ever taken a dog to obedience class? FORMCHECKBOX Yes FORMCHECKBOX No Will you take your new dog to obedience class? FORMCHECKBOX Yes FORMCHECKBOX NoDo you understand that the Humane Society of South Central Michigan does not guarantee the health of its animals and that additional medical care at your personal expense may be necessary? FORMCHECKBOX Yes FORMCHECKBOX NoPersonal References (non-family members)Name: FORMTEXT ?????Phone: FORMTEXT ?????Relationship: FORMTEXT ?????Name: FORMTEXT ?????Phone: FORMTEXT ?????Relationship: FORMTEXT ?????OverI have seriously considered all aspects of owning a pet and I am aware of the time and money involved. I am prepared to make a commitment to the pet being adopted for its lifetime. HSSCM has the right and responsibility to assist me in selecting a pet that is well suited to me and my lifestyle. I certify that the answers on this profile are accurate and understand that false information will result in nullifying the adoption. I understand that this questionnaire remains the property of the Humane Society.SignatureDate ................
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