Canine (Dog) Adoption Application

Applicant & Household Member Information

Primary Applicant Full Name

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Date of Birth

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Phone Number

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Email Address

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Street Address

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City/State/Zip

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Additional Adult Household Members

Please list the full name (first, middle, last) for all other individuals aged 18 or older residing in the home.

Household & Living Environment

Housing Type House Apartment Condo Mobile Home

Please correct your Housing Type.

Ownership Own Rent Live with Parents

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If renting, landlord name and phone

If you own, whose name is the home titled in?

Do you have a fenced yard? Yes No

Please correct your Do you have a fenced yard?.

If yes, fence height and material

Does the fence completely enclose the yard? Yes No

Please correct your Does the fence completely enclose the yard?.

If you do not have a fence, how will the dog safely exercise and relieve themselves?

Number of adults in the home

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Number of Children

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Is anyone in the household allergic to pets? Yes No

Please correct your Is anyone in the household allergic to pets?.

Current & Past Pets (Last 5 Years)

Pet 1 (Name/Breed/Age)

Spayed/Neutered Yes No

Pet 2 (Name/Breed/Age)

Spayed/Neutered Yes No

Pet 3 (Name/Breed/Age)

Spayed/Neutered Yes No

Pet 4 (Name/Breed/Age)

Spayed/Neutered Yes No

Pet 5 (Name/Breed/Age)

Spayed/Neutered Yes No

Current or Past Veterinarian/Clinic Name

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Clinic Phone Number

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Name on Veterinary Records

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Please provide two personal references who do not live with you and are not related to you.

Full Name

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Relationship to Applicant

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Phone Number

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Please correct your Email.

Relationship to Applicant

Your New Pet Preferences

I am applying to adopt a Dog Cat No specific animal yet

Please correct your I am applying to adopt a.

Name of specific animal (if known)

Desired age range: Puppy/Kitten Young Adult Senior

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Desired energy level Low (Couch potato) Moderate High (Running buddy)

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Where will the dog sleep at night? Crates Master Bedroom Living Room Outside

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Where will the dog stay when home alone? Loose in house Crate Gated room Outdoor kennel

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How many hours will the dog be left entirely alone daily?

Please correct your How many hours will the dog be left entirely alone daily?.

Who will care for the dog when you are at work or traveling?

Please correct your Who will care for the dog when you are at work or traveling?.

On average, how much daily exercise will you provide the dog? Short walks / Potty breaks only 1–2 hours of brisk walking or running High-intensity activities (hiking, agility, dog parks) Fenced in yard activities

Please correct your On average, how much daily exercise will you provide the dog?.

What is your budget preference for annual dog food, grooming, and veterinary care? Standard budget care Moderate care High / Specialized medical care

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Desired size: Small (under 20 lbs) Medium (20–50 lbs) Large (50–90 lbs) Giant (90+ lbs)

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Experience level with dogs: First-time owner Intermediate Highly experienced / Breed expert

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Are you willing to adopt a dog that requires active training or behavior modification? Yes No

Please correct your Are you willing to adopt a dog that requires active training or behavior modification?.

House-training/Leash pulling Yes No

Please correct your House-training/Leash pulling.

Mild separation anxiety Yes No

Please correct your Mild separation anxiety.

Reactivity to other animals Yes No

Please correct your Reactivity to other animals.

What traits are most important to you in your new dog? (Check all that apply) Good with young children Good with other dogs Good with cats / Low prey drive Already fully house-trained Protective / Guard dog instincts

Please correct your What traits are most important to you in your new dog? (Check all that apply).

Notice of Automatic Denial & Application Policies

Please review the following criteria and shelter policies carefully. The Worcester County Humane Society reserves the right to automatically deny any application for the reasons listed below:

Untruthful Statements: Providing false, misleading, or exaggerated information anywhere on this application.
Incomplete Application: Leaving required sections, contact numbers, or signatures blank. Significant delays occur due to questions that arise due to incomplete information.
Failed Veterinary Check: Past or present pets not up to date on legally required vaccines (e.g., Rabies), missing regular medical care, not tested nor on Heartworm Preventative (dogs).
Intact Pets: Current pets in the household that are not spayed or neutered without a verified medical exemption from a veterinarian.
Landlord Disapproval: Lack of consent from a landlord, or applying for a pet breed/size restricted by your lease or HOA policy.
History of Animal Abuse: Any past convictions, citations, or documented history of animal neglect, abuse, or abandonment.
History of Violent Offenses: Any past convictions, citations, or documented history of violent crimes, domestic abuse, or assault.
Age Requirement: Applicant is under 21 years of age.

Important Shelter Policies

Shelter Visits: Please note visits to the shelter are strongly encouraged to meet the pet you are interested in, but not required to adopt.
Trait Matching: Applications may not be processed if desired pet traits do not match any animal we have.
Application Expiration: WCHS does not keep lists; approved applications are only good for 30 days.
No Holds / Multiple Applications: We do not hold or reserve any animals, and do accept more than one application on a specific animal, until the animal has left the building and been officially adopted.

Under what circumstances would you return or surrender an adopted pet?

Please correct your Under what circumstances would you return or surrender an adopted pet?.

I have read, understand, and agree to follow all of the Worcester County Humane Society policies, rules, and automatic denial criteria listed above.

Please correct your Under what circumstances would you return or surrender an adopted pet?.

Acknowledgement & Signature

By signing below, I certify that all information provided is true and correct. I authorize the Worcester County Humane Society to contact my landlord, personal references, and veterinarian to verify this information.

Signature

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Date

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Office Staff Reviewer

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Worcester County Humane Society | No Kill Shelter

Applicant & Household Member Information

Additional Adult Household Members

Household & Living Environment

Current & Past Pets (Last 5 Years)

Personal References

Reference 1

Reference 2

Your New Pet Preferences

Notice of Automatic Denial & Application Policies

Important Shelter Policies

Acknowledgement & Signature