Headin' Home Rescue

Adoption Application Info

If you have trouble submitting this form, you may print it or the alternate form, then submit it via email or in person.
Incomplete applications will not be considered. Please be sure to provide explanations where requested.
If you are completing an adoption application, please let your current veterinarian know that we will be calling to check your pet's history. Many veterinarians will not release information without your consent, so this will save us time in the application process.

E-mail Address: *

Adopter's Name *

Age *

Street Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Work Phone *

Are you expecting a child or planning a family? *

Yes
No

How many children live in your home? *

Names and ages of children *

Besides those people listed above, are there others residing in your home? *

Yes
No

Names, ages, relationship of other residents *

Is everyone in the household in agreement about adopting a pet? *

Yes
No
Haven't discussed
Surprise

Is anyone in your home allergic to animals? *

Yes
No

If yes, to what specific kinds of animals?

Does anyone in your home have asthma? *

Yes
No

Do you own or rent your home? *

Own
Rent

If you rent, please provide name and phone number of your landlord:

If renting, please indicate any restrictions on pets (size, breed, declawed cats, etc)

Please describe your current dwelling: *

How long have you lived at your current address? *

If less than two years, please provide your previous address:

In what type of neighborhood is your home located?

Does your city, township or county have a dog ordinance banning the ownership of specific breeds of dogs? *

Yes
No

Does your home have a yard? *

Yes
No

Is there a securely fenced in area for a dog? *

Yes
No

If not, explain how and where you will allow the dog to exercise and relieve itself:

If your yard is fenced, please describe what kind:

Do you have other pets at this time? *

Yes
No

If yes, are they spayed or neutered?

Yes
No

If not, why are they not spayed or neutered?

If other dogs, are they currently on heartworm prevention?

Yes
No

If yes, what type?

Where do you get your heartworm prevention from?

Vet
Online Pharmacy
Other

If not on heartworm prevention, please explain

Are the other pets current on their vaccinations?

Yes
No

If not, please explain

Are the other pets indoors or outdoors?

Indoors
Outdoors

Please describe the other pets in your home (type, gender, etc)

Have you owned dogs or cats previously? *

Yes
No

If yes, please list names, breeds and why you no longer have them:

Where will your new pet live? *

Indoors
Outdoors

Which pet are you interested in adopting? *

What attracted you to this pet that you are applying to adopt?

Do you have any experience with this breed? (If yes, please explain)

What role would you like your new pet to play in your life?

Please describe where the pet will stay when you are home:

Please describe where the dog will stay when you are away during the day

Please describe where the dog will sleep at night:

Do you currently have a crate for the dog?

Yes
No

Do you plan to use a crate for the dog?

Yes
No

Why or why not?

Who will be the primary caretaker of this pet? *

Have you adopted a pet before? *

Yes
No

If you have adopted before, please tell us from where (name, phone number)

Please provide us with the name, address, and phone number of your current veterinarian (NOTE: some vets require that you call and authorize them to talk to us). *

If you have used any other veterinarian(s), please list names and phone numbers. Indicate which pets they treated.

Employer *

Employer Phone *

Reference #1 Name (not a relative) *

Reference #1 Phone Number *

Reference #1 Email

Reference #2 Name (not a relative) *

Reference #2 Phone Number *

Reference #2 Email

Reference #3 Name (not a relative) *

Reference #3 Phone Number *

Reference #3 Email

The information provided in this application (in its entirety) is true to the best of my knowledge as of the date on this application. I agree that either my signature on this copy or submission of this form by email will constitute a legally signed document (enter your name here to *

* Required Build Your Own Contact Form

For more information, please contact us: