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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:
*
KS
AL
AK
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
Washington D.C.
WV
WI
WY
Zip Code:
*
Primary Phone Number:
*
Email:
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Section II - Household Information
Where do you live?
*
House
Mobile Home
Apartment/ Condo/ Duplex
Dorm
Farm
Townhome
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?
*
Yes
No
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?
*
No
Yes
Have you ever brought one of your pets to Jefferson County Humane Society?
*
No
Yes
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
Home
Adopt Hub
Adopt A Dog
Adopt a Cat
Adoption Guidelines
Adoption Application
Volunteer
Donate
Events
About Us
Happy Tails
Services
Resources
Contact Us