Adoption Application

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Section I - Adopter Information

* Indicates required field

Name of Animal Applying For: *

If you don't have someone in mind, give us an idea of what you're looking for.

Are you 18 years or older? *

Yes No

If you aren't 18, you'll need a parent or guardian to fill out this application.

Full Name: *

First

Last

Street Address: *

City: *

State: *

Zip Code: *

Primary Phone Number: *

Email: *

Section II - Household Information

Where do you live? *

Do you own your home? *

Yes No

Do you rent? *

Yes No

Do you live with your parents? *

Yes No

Landlords name and phone number. (Parents name and phone number if living with them.) *

Are you planning on moving in the next year? *

Yes No

If moving in the next year, what are you planning on doing with your pets? *

Why are you looking to adopt? (check all that apply) *

Companion for Person Outdoor Only Family Pet Protection/ Guard Dog Companion for Pet Hunting Gift Breeding Mousing Barn Cat Business Mascot

Number of people in your household: *

What type of activities do you envision doing with your new pet? *

How will you confine your new pet to your property? *

Where will this pet be kept during the day? *

How many hours will this pet be home alone with no human contact? *

Do you or anyone in your family have allergies to dogs or cats? *

Yes No

List ages of children in household. Put "none" if no children are present. *

Who will supervise your children when they interact with you new pet? *

Who will be responsible for this pet? *

In your absence, who will care for this pet? *

Who will be responsible for socialization and training? *

What behaviors will you be unwilling to work with? *

What type of grooming is necessary for the type of pet you have chosen? *

What do you estimate the yearly expense of owning this pet? *

List all pets that have lived with you in the past 5 years. Name/Age/Sex/Breed *

If you no longer have any of the animals listed, please explain. *

It may take your new pet several weeks to adjust to your home, longer if other pets are involved. Are you prepared to allow this much time to adjust? *

Section III - Vet Information

What vet do you plan on using? *

Address of veterinarian: *

Phone number for veterinarian reference. *

Are your pets vaccinations up to date? *

Yes No

Have you ever applied to or adopted from Jefferson County Humane Society? *

Have you ever brought one of your pets to Jefferson County Humane Society? *

By typing in my name below and submitting this form, I certify that the information I have given is true and that I recognize that any misrepresentation of facts may result in my losing the privilege of adopting a pet. I understand that the Jefferson County Humane Society has the right to deny my request to adopt an animal, and I authorize investigation of all statements in this application. I understand that this application is the property of the Jefferson County Humane Society, Inc. *

Submit Form

Jefferson County Humane Society ~ 15295 K-4 Highway ~ Valley Falls, KS 66088 ~ 785-945-6600 ~ jfcountypets@gmail.com

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Home
Adopt
Donate
- Donate >
  - Fetch List
  - Amazon Smile Donation
Volunteer
- Foster
- Volunteer Application
Community
About Us
- Contact Us >
  - Online Form Submitted Page