Canine (Dog) Adoption Application

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 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?

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.

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?

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

Who has been your veterinarian?

Veterinarian's phone

Veterinarian's address

Agreed to terms *

I agree.

Please correct - Agreed to terms.

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

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.

Worcester County Humane Society | No Kill Shelter

My Preferences

About Me and My Home

My Habits

Contact Info

What pets have you owned in the past?

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