Canine (Dog) Adoption Application

Please note:
Incomplete applications will NOT be processed.
A current relationship with a veterinarian is required. If you do not have a veterinarian at the time of application, please secure one within 24 hours of submission.
** A vaccine clinic location does NOT qualify.

    Thank you for your submission.
    
        	
        
        
        
        

        
                My Preferences
        

        
            
                Are you interested in adopting a particular dog?
                
            

            
                Have you adopted a pet from us before? *
                
                    
                         N
                    

                    
                         Y
                    
                
                 Please correct - Have you adopted a pet from us before?
            
        


        
            
                Are you affiliated with The Worcester County Humane Society or do you know someone affiliated with us?
                
            
        

        
            
                What type of dog are you looking for?
                
                    
                         Adult
                    

                    
                         Female
                    

                    
                         Large (40 lbs and larger)
                    
                    
                    
                         Male
                    
                    
                    
                         Medium (20 to 40 lbs)
                    
                    
                    
                         Puppy
                    
                    
                    
                         Senior
                    
                    
                    
                         Small (20 lbs or less)
                    
                    
                    
                         Special Needs: Behavioral
                    
                    
                    
                         Special Needs: Medical
                    
                
            
        

        
            
                What energy level are you looking for in a dog? *
                
                    
                         High energy
                    
                    
                    
                         Low energy
                    
                    
                    
                         Medium energy
                    
                
                 Please correct - What energy level are you looking for in a dog?
            
        


        

        
            About Me and My Home
        

        
            
                What type of home do you live in? *
                
                    
                         Apartment
                    

                    
                         Condo
                    
                    
                    
                         Duplex
                    
                    
                    
                         House
                    
                    
                    
                         Mobile
                    
                    
                    
                         Other
                    
                
                 Please correct - What type of home do you live in?
            
        

        
            
                Do you rent or own your home? *
                
                    
                         Own
                    
                    
                    
                         Rent
                    
                
                 Please correct - Do you rent or own your home?
            
        

        
            
                Landlord's Name
                
            

            
                Number of adults in your household: *
                
                 Please correct - Number of adults in your household:.
            
        
            
                Landlord's phone number
                
            
        

        
            
                Number of children (under age 18) in your home *
                
                 Please correct - Number of children (under age 18) in your home.
            

            
                Ages
                
            

            
                Are there any persons who regularly visit the home (grandchildren, family members, etc)? Explain and list visitor(s) ages below.*
                
                 Please correct - Are there any persons who regularly visit the home (grandchildren, family members, etc)? Explain and list visitor(s) ages below.
            
        


        

        
            My Habits
        
        
        
            
                How much time daily will you spend with your dog? *
                
                 Please correct - How much time daily will you spend with your dog? *
            
        
        
        
            
                Does your home have a dog or cat door? *
                
                    
                         No
                    
                    
                    
                         Yes, cat door
                    
                    
                    
                         Yes, dog door
                    
                
                 Please correct - Does your home have a dog or cat door?
            
        
        
        
            
                Describe the living environment for your new dog: *
                
                    
                         Basement, garage, porch or sunroom
                    
                    
                    
                         House pet, except for exercise and elimination
                    
                    
                    
                         Mostly outside, inside in bad weather
                    
                    
                    
                         Other
                    
                    
                    
                         Outside with a dog house
                    
                    
                    
                         Outside with access to barn or other building
                    
                
                 Please correct - Describe the living environment for your new dog:
            
        
        
        
            
                How many hours each day will your dog be home alone without human companionship? *
                
                 Please correct - How many hours each day will your dog be home alone without human companionship?
            
        
        
        
            
                When home alone, your dog will be: (check all that apply) *
                
                    
                         Dog daycare
                    
                    
                    
                         In a crate inside house
                    
                    
                    
                         In a garage, sunroom, basement
                    
                    
                    
                         Inside or outside in fenced yard, using doggie door
                    
                    
                    
                         Loose inside house
                    
                    
                    
                         Other
                    
                    
                    
                         Outside free to roam in unfenced area
                    
                    
                    
                         Outside in fenced area if nice weather
                    
                    
                    
                         Outside secured to a chain or cable
                    
                
                 Please correct - When home alone, your dog will be: (check all that apply).
            
        
        
        
            
                What type of obedience training do you plan to use? *
                
                    
                         I will train myself
                    
                    
                    
                         In-home professional trainer
                    
                    
                    
                         Obedience classes
                    
                    
                    
                         Other
                    
                
                 Please correct - What type of obedience training do you plan to use?
            
        
        
        
            
                Other Obedience Training
                
            
        
        
        
            
                Would you allow our representative to visit your home before the adoption is completed? *
                
                    
                         No
                    
                    
                    
                         Yes
                    
                
                 Please correct - Would you allow our representative to visit your home before the adoption is completed?
            
        


        

        
            Contact Info
        

        
            
                First Name *
                
                 Please correct - First Name.
            
        
            
                Middle Name
                
            
        
            
                Last Name *
                
                 Please correct - Last Name.
            

            
                Date of Birth *
                
                 Please correct - Date of Birth.
            
        

        
            
                Home Phone *
                
                 Please correct - Home Phone.
            

            
                Cell Phone
                
            

            
                Email *
                
                 Please correct - Email.
            
        

        
            
                Address *
                
                 Please correct - Address.
            

            
                City *
                
                 Please correct - City.
            

            
                State *
                
                 Please correct - State.
            

            
                Zip Code *
                
                 Please correct - Zip Code.
            
        

        
            
            Do you own or rent? *
            
                
                     Own
                
                
                
                     Rent
                
            
             Please correct - Do you own or rent?
            
        

        
            
                List previous address.
                
            
        

        
                
                    How long have you lived at the address? *
                    
                     Please correct - How long have you lived at the address?
                
            

        
            
            Are you *
            
                
                     Attending school
                
                
                
                     Homemaker
                
                
                
                     Other
                
                
                
                     Retired
                
                
                
                     Working
                
            
             Please correct - Are you
            
        

        
            
                Are you other
                
            
        

        
            
                Who has been your veterinarian?
                
            
        

        
            
                Veterinarian's phone *
                
                Please provide your Veterinarian's phone number
            
        

        
            
                Veterinarian's address *
                
                Please provide your Veterinarian's address
            
        

        
            
            Agreed to terms *
            
                
                     I agree.
                
            
             Please correct - Agreed to terms.
            
        

        
            
                How did you hear?
                
                    
                         Facebook
                    
                    
                    
                         Fundraiser
                    
                    
                    
                         Other
                    
                    
                    
                         Website
                    
                
            
        

        
            
                hear other
                
            
        


        

        
            What pets have you owned in the past?
        

        
            
                Pets Name 1
                
            

            
                Breed 1
                
            

            
                Pet Age 1
                
            
        

        
            
                Pet Gender 1
                
                    
                         F
                    
                    
                    
                         M
                    
                
            

            
                Spayed/Neutered 1
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            

            
                Still have this pet? 1
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            
        

        
            
                Pets Name 2
                
            

            
                Breed 2
                
            

            
                Pet Age 2
                
            
        

        
            
                Pet Gender 2
                
                    
                         F
                    
                    
                    
                         M
                    
                
            

            
                Spayed/Neutered 2
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            

            
                Still have this pet? 2
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            
        

        
            
                Pets Name 3
                
            

            
                Breed 3
                
            

            
                Pet Age 3
                
            
        

        
            
                Pet Gender 3
                
                    
                         F
                    
                    
                    
                         M
                    
                
            

            
                Spayed/Neutered 3
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            

            
                Still have this pet? 3
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            
        

        
            
                Pet Name 4
                
            

            
                Breed 4
                
            

            
                Pet Age 4
                
            
        

        
            
                Pet Gender 4
                
                    
                         F
                    
                    
                    
                         M
                    
                
            

            
                Spayed/Neutered 4
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            

            
                Still have this pet? 4
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            
        

        
            
                Pet Name 5
                
            

            
                Breed 5
                
            

            
                Pet Age 5
                
            
        

        
            
                Pet Gender 5
                
                    
                         F
                    
                    
                    
                         M
                    
                
            

            
                Spayed/Neutered 5
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            

            
                Still have this pet? 5
                
                    
                         N
                    
                    
                    
                         Y
                    
                
            
        


        

        
            Please list 2 personal references (not related to you)*
        

        
            
                Reference Name 1 *
                
                 Please correct - Reference Name 1.
            

            
                Reference Phone 1 *
                
                 Please correct - Reference Phone 1.
            
        

        
            
                Reference Name 2 *
                
                 Please correct - Reference Name 2.
            

            
                Reference Phone 2 *
                
                 Please correct - Reference Phone 2.