PRE-ADOPTION - DOG
 
So that we may be assured that the animal you want to adopt will be best suited for you,
your home and lifestyle, we would like you to provide us with the following information.
This form should take approximately 10-20 minutes to complete. Thank you for your cooperation
 
  Name and Description of Dog that you’re interested in:
 
   
   
I am at least 21 years old

yes     no   
I have discussed the health conditions of this animal with a staff member

yes      no   

I have discussed behavioral issues this animal may have with a staff member

yes      no  
I want this animal to be an indoor pet and to live as a part of my family for the rest of his/her life

yes      no   
I have the financial means to care for a new pet now and many years from now (even if they are sick or injured)

yes      no  
I am patient and responsible enough to work with a love a new pet through his/her issues

yes      no  
I have considered how adopting a pet will affect my life now and in the future (i.e. physical requirements over time, changes in family circumstance, new baby, unexpected move, retirement, etc)

yes      no  
I have considered how a new pet will affect my ability to leave town / go on vacation and that the animal will require a sitter, boarding, etc.

yes      no  
Where did you FIRST see/hear about this pet?  
  Petfinder or ECCHA website  
  Facebook  
  PETSMART  
  In person at the shelter (ECCHA)  
  Newspaper  
  TV  
  Other:  
ABOUT YOU

  

Name:
 

Primary Phone Number:
(xxx-xxx-xxxx)

Secondary Phone Number:
(xxx-xxx-xxxx)
Street Address: 
How long have you lived at the above address?
City:
ZIP:
 
State:
Email:
 
Date of Birth (mm/dd/yyyy):
PLEASE CONFIRM EMAIL:
  *
Place of Employment
Work Phone#
  (xxx-xxx-xxxx)
Time with Current Employer
years
Occupation:
 
Household Information:
Are other people in your home experienced with dogs? yes no  
Does everyone in the house want to get a new dog? yes no  
Have all the members of your home met the animal? yes no  
Household activity level: quiet active very active
 
Please list the names and ages of other members in your household:
Name:
Age:    
Name:
Age:    
Name:
Age:    
Name:
Age:    
Name:
Age:    
Name:
Age:    
Name:
Age:    
Name:
Age:    
You live in: House Apartment
Trailer/mobile home
If trailer home -which park?
Do you:  Own Rent Live with family Mobile home/I own the land    
If you rent or live with family, do you have the homeowner’s permission to have a dog? Yes No
If you rent or live with family, what is the homeowner’s name?
What is their phone number? (xxx-xxx-xxxx)
Pre-Adoption Questions (Please answer all)
Why have you decided to adopt a dog?
What will you do to ensure you will be a responsible dog owner?
What do you know about the breed(s) you want to adopt (breed characteristics, potential health issues, etc.)?
If you had to move in the future, what would you do with your pet(s)?
Do you plan to breed your dog/let it have puppies? Yes     No      N/A
Do you plan to spay/neuter your dog? Yes     No Already Altered
Have you ever given a dog up because it didn't work out?   Yes     No
If so, please explain the circumstances and what happened to it:
 
Do any family members have allergies to dogs? Yes     No
Are you familiar with crate training? Yes     No
Have you designated a primary caregiver for the new dog? Yes     No
Please check any/all characteristics that best describe the primary caregiver:
    Retired
    Stay-at-Home Parent
    Employed Part-Time
    Employed Full-Time
    College Student
    Child/Adolescent
    Other

How will you exercise your dog?
How do you intend to train your new dog?   On my own Obedience class  other   
If other than obedience class, please tell us about your training plan:  
Are you willing to deal with unforeseen circumstances this dog may present? Yes     No  
How do you plan to deal with:
  • Dog / Food Aggression
  • Poor Manners
  • Barking
  • Housetraining

• Mouthing / play biting
What brand of food will you feed your dog?
Where will you primarily keep your dog? Inside          Outside          Both 
When you are not at home, the dog(s) will be:

Crate Free roam of house Outside

Other (explain)

When outside, how will the dog be confined? Fenced Yard, Running Cable/lead line, other
If the dog will be kept in an outdoor enclosure, please describe the enclosure and note when they will be confined to it (during what hours of the day, and what times of year, etc):
If you have any additional comments, please put them here:
Information About Your Pet(s)
Please check this box if you do not own, and have not owned any pets in the past five years: (if checked, you do not need to fill out this section)
What veterinary hospital do you use (or do you plan to use)?
Under whose name are the veterinarian hospital records?
Please list your veterinarian's phone number (xxx-xxx-xxxx)

Please tell us about the pets that have owned you in the last five years
(whether or not you still own them) - if you need more room list in comment box below:

Pet#1:    
  Type of pet:
  If not dog or cat, what type?
  Name
  Breed:
  Gender:
  Spayed/Neutered?

  Housed
  Age?
  Years Owned?
  Still Owned?   yes          no
     
Pet #2    
  Type of pet:
  If not dog or cat, what type?
  Name
  Breed:
  Gender:
  Spayed/Neutered?

  Housed
  Age?
  Years Owned?
  Still Owned?   yes          no
     
Pet #3    
  Type of pet:
  If not dog or cat, what type?
  Name
  Breed:
  Gender:
  Spayed/Neutered?

  Housed
  Age?
  Years Owned?
  Still Owned?   yes          no
     
Pet #4    
  Type of pet:
  If not dog or cat, what type?
  Name
  Breed:
  Gender:
  Spayed/Neutered?

  Housed
  Age?
  Years Owned?
  Still Owned?   yes          no
     
Pet #5    
  Type of pet:
  If not dog or cat, what type?
  Name
  Breed:
  Gender:
  Spayed/Neutered?

  Housed
  Age?
  Years Owned?
  Still Owned?   yes          no
     
Pet #6    
  Type of pet:
  If not dog or cat, what type?
  Name
  Breed:
  Gender:
  Spayed/Neutered?

  Housed
  Age?
  Years Owned?
  Still Owned?   yes          no
  If you no longer have any of the pets listed above, please explain what happened to them:
The undersigned applicant hereby grants the Eau Claire County Humane Association permission to confirm any information provided in this application with any appropriate third party source, including landlords, veterinarians, etc. The information obtained will be held in confidence and used only by the Eau Claire County Humane Association for purposes of this adoption application. I certify that all the information on this application is true and complete. I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I also understand that this adoption application is at its own discretion. It is specifically understood that the Eau Claire County Humane Association reserves the right to deny any adoption application at its own discretion.
Typing your name below will serve as legal signature. By signing below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for disallowing the adoption of rescue Cat and possible removal of said Cat from my home. Applicant must be 18 years of age or older. We reserve the right to refuse any applicant.
 
   
Signature:
Date: 
Driver's license #:
 
Security Code
           
Enter Security Code