Survey - Special Adoption Application - Wisconsin Humane Society

Special Adoption Application

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The Wisconsin Humane Society
Special Adoption Application

Question - Required - What is the name of the special needs animal you would like to adopt?

Section I

We are committed to finding the best home for every animal entrusted to our care and ensuring that the animal you are interested in adopting is best suited to you, your home and lifestyle; therefore, we would appreciate your providing us with the following information. We review each application carefully to ensure the best fit for each animal and guardian.

Please tell us about yourself:

Name:

Title	First Required	Middle Required	Last Required	Suffix

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	State Required	ZIP Required

Country:

Phone Number: Required

Yes, I would like to receive e-mail from The Wisconsin Humane Society

Email Format:

Yes, I would like to receive postal mail from The Wisconsin Humane Society

Remember me.

Section II

Please complete this questionnaire for the household in which your companion animal will reside.

Question - Required - If you rent or live in a condo, does your landlord/home association allow pets?

Question - Not Required - Landlord Name (if applicable):

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Landlord Phone (if applicable):

Question - Required - Do you own your own home?

Question - Required - Do you have a fenced-in yard?

Question - Required - How many adults live in your home?

Question - Required - How many children live in your home?

Question - Not Required - Please list their ages:

Question - Required - Do all adults in your household know that you plan to adopt?

Question - Required - Does anyone in your home have allergies to animals?

Question - Not Required - If yes, can these allergies be controlled by medication?

Question - Required - Please check all that apply. Is the dog being adopted as a:
Please make between 1 and 8 selections from the choices below.

	Watch Dog
	Gift
	Hunting Dog/Mousing Cat
	Guard Dog
	Companion for Other Animal
	Fighting Dog
	Companion
	Other

Question - Not Required - If you chose other, please explain:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - Who will be this animal's primary caretaker (i.e. feed, train, exercise, groom, etc.)?

Question - Required - How much experience have you had with this type of animal?

Question - Required - What is the activity level of your household?

Question - Required - Have you ever been convicted of or received citations for the violation of Federal, State or Municipal animal codes?

Section III

Question - Required - How many companion animals have you had over the past five years?

Please provide additional information about these animals:

Question - Not Required - First animal species:

Question - Not Required - First animal breed:

Question - Not Required - Where did the first animal stay?

Question - Not Required - First animal age (or passed away):

Question - Not Required - Name of first animal:

Question - Not Required - Was the first animal spayed or neutered?

Question - Not Required - Second animal species:

Question - Not Required - Second animal breed:

Question - Not Required - Where did the second animal stay?

Question - Not Required - Second animal age (or passed away):

Question - Not Required - Name of second animal:

Question - Not Required - Was the second animal spayed or neutered?

Question - Not Required - Third animal species:

Question - Not Required - Third animal breed:

Question - Not Required - Where did the third animal stay?

Question - Not Required - Third animal age (or passed away):

Question - Not Required - Name of third animal:

Question - Not Required - Was the third animal spayed or neutered?

Question - Not Required - If you have more than three companion animals, please provide the other animals' information here.

Question - Not Required - If you no longer have any of the above animals, please explain what happened to him, her or them.

Question - Required - Are you aware of the annual routine vaccinations recommended for the health and protection of your animal?

Question - Required - Are all the animals in your home up to date with their vaccinations?

Question - Required - Please provide the name of your clinic and veterinarian.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - Whose name is listed on the account?

Question - Required - Are you prepared to assume the financial responsibilities of providing your dog with adequate food, medical care, housing, training, toys, etc. (approximately $300 to $1,000 per year)?

Question - Required - What do you plan on feeding your new companion?

(Maximum response 255 chars, approx. 5 rows of text)

Section IV

Question - Required - How much time are you willing to let your new companion adjust to your household?

Question - Required - Where will you keep your animal during the day and night?

Question - Required - How many hours will your dog be kept outside or how many hours will you let your cat spend outside?

Question - Not Required - If your animal is kept outside, what type of shelter will be provided?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - How many hours will your animal be left alone?

Question - Required - How will your companion be exercised?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - Who will be exercising your companion?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - Please provide a brief description of how you would address destructive behavior like play biting, chewing, scratching or barking.

Question - Required - How often do you travel and who will be caring for your animal while you are away?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - During the new transition, dogs and cats are likely to have housetraining accidents and adjustment issues. How would you address this problem?

Question - Required - Change is inevitable in one's lifetime. What will you do if you move or can no longer care for your animal?

(Maximum response 255 chars, approx. 5 rows of text)

Section V

I certify that I am at least 18 years of age and the information I have given is true. I recognize that the misrepresentation of facts may result in my losing the privilege of adopting an animal. I authorize any and all verification of statements made in the application and I understand that the Wisconsin Humane Society has the right to deny my application.

I am fully aware that I am adopting a living creature and as such, the Wisconsin Humane Society is unable to guarantee the health of the animal.

If this animal becomes ill, I certify that I am financially and emotionally prepared to treat this animal at my own expense.

Question - Required - By typing my full name here, I agree to the above statements.