Adoption Application

"*" indicates required fields

Thank you for your interest in adopting an animal from the Brown County Humane Society (BCHS). In an effort to ensure the best possible placement for the animals in our care, we ask that you fill out the following application completely. All information will be kept confidential. The person signing this adoption application must be the intended owner of the animal, if the adoption is approved. Additionally, please note that you must be at least 18 years of age or older to adopt an animal from BCHS.

Type of animal interested in (ex: dog, cat, rabbit, etc.):*

Name of animal interested in adopting, if known:

PERSONAL INFORMATION

Your Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alternate Phone

Email*

How old are you?

HOUSEHOLD INFORMATION

Type of home you live in:*

How long have you lived at this residence?*

Do you own/rent your home?*

If you chose other arrangement, please explain

If you do not own the home, does homeowner allow the type of animal you will be adopting?*

Please provide homeowner information below.

If your name is not listed as owner of property, provide name and phone # for property owner:

First Last

Phone

How many adults live in your house?*

Ages of children in house:*

Are all members of your household in agreement about adopting an animal?*

Do any members of your household have asthma or animal related allergies?*

If yes, please describe:

In the event of a personal or family emergency, who would care for the animal you are adopting, or what arrangement would you make for the animal’s care?*

CURRENT ANIMALS IN YOUR HOUSEHOLD

Are there currently other animals in your home:*

If yes, list the species and ages. For dogs, also list the breed(s):

Are all of the animals in your home up-to-date on vaccinations?*

If you currently have a dog(s), does he/she have a current county license tag?*

If yes, what County?

Are your dogs/cats spayed/neutered?*

If any of your current pets are not up-to-date on vaccinations, not spayed or neutered, or do not have a required county license tag please explain:*

Type N/A if not applicable

Please provide the name, address, and phone number of your current veterinarian or the veterinary practice you intend to use:*

MATCHMAKING INFORMATION

Describe your household activity level (calm, highly active, etc.):*

If adopting a cat, are your current pets cat-tested?*

Are you looking for an indoor or outdoor pet?*

Indoor

Outdoor

Where will your adopted dog be when you are home?*

If adopting a dog, how many hours will your dog be alone during the day?*

Type N/A if not adopting a dog.

If adopting a dog, where will your dog be when no one is home?*

If adopting a dog, do you have a fenced yard?*

If yes, what type and height of fence?*

Type N/A if not adopting a dog.

If not, how will you keep dog on property when outside?*

Type N/A if not adopting a dog or if you have a fence.

ADDITIONAL INFORMATION

Are you willing and able to accept the long-term commitment and financial expenses that come with owning and properly caring for the animal you are seeking to adopt?*

Have you ever had to return, rehome or given an animal away?*

If yes, who was your pet given to?*

Have you ever had an animal lost or stolen?*

Have you ever had to retrieve your animal from a shelter or animal control?*

If you have to move, what would you do with your adopted pet?*

For what reasons would you consider returning or re-homing your adopted pet?*

By signing this application, I am stating that I have answered all questions completely and truthfully. In the event that BCHS (at any later time) discovers a falsehood, the adoption can be annulled, and the animal seized. By signing this application, I acknowledge that I have been informed that BCHS reserves the right to deny any application.

Applicant's Signature:*

Date*

* Office Use Only *

Application Approved:

If not, why

Staff Signature:

Date