Dog Adoption Application - Middletown Humane Society

Name of animal you are interested in: *

Name *

First

Last

Address *

City *

State *

Zip *

Home Phone *

Work Phone

Cell Phone

Email *

Employer *

What is your current age? *

When was the last time you owned a pet? *

Why don't you own that pet currently? *

Will this be your first dog? *

Yes
No

Please list the pets you have had in the past 5 years:

Please include Name, Age, Breed, Sex, If Neutered, Still Have?, if No, Why?

Pets Owned 2

Please include Name, Age, Breed, Sex, If Neutered, Still Have?, if No, Why?

Pets Owned 3

Please include Name, Age, Breed, Sex, If Neutered, Still Have?, if No, Why?

Pets Owned 4

Please include Name, Age, Breed, Sex, If Neutered, Still Have?, if No, Why?

Please provide your veterinarian’s name, address and phone number (if known): *

Have they been spayed or neutered?

Yes
No
I don't know

Are they current on vaccinations?

Yes
No
I don't know

Will you keep this dog up to date on vaccinations?

Yes
No

Have you ever turned your dog in to a shelter?

Yes
No

If 'Yes', please explain:

Have you ever had a pet euthanized for medical reasons?

Yes
No

If 'Yes', please explain: (copy)

If you have pets, will they adjust to a new dog entering the house?

Yes
No
I don't know

Why do you want this dog?

Where will the dog sleep? (Ex: basement, garage, kennel, dog bed, people bed, etc.)

Does everyone living in your home know about and agree with your decision to adopt a dog?

Yes
No

If not, why?

How many adults are in your household?

What are the adults' ages and relationships to you?

How many children?

Please indicate ages of children.

Does any member of your household have an allergy to dogs?

Yes
No

Is someone home during the day?

Yes
No

If yes, who?

How many hours each day will the dog be alone?

Please provide details.

Where do you live?

If other, please explain:

Do you own or rent your home?

Own
Rent

If you own, who is the owner on record?

If you rent, may we contact the owner to obtain permission for this dog to live in your home?

Yes
No

Owner's name and phone number:

Do you have a completely fenced yard?

Yes
No

If fenced, please describe type of fence and height:

Do you have a dog door? *

Yes
No

How will you housebreak your dog/puppy? *

Crate
Free Roam
Keep outside until he/she learns
Other

Are you familiar with crate training? *

Yes
No

Where will you keep the dog? *

If other, please explain:

Are there times when the dog will be tied up? *

Yes
No

If yes, when?

Would you be willing and able to exercise the dog on a regular basis? *

Yes
No

Exercise Method:

If you go away for a few days, or on a vacation, who will take care of the dog? *

If you move, will you take the dog with you? *

Yes
No

What behavior will you have the most difficulty dealing with? *

What would you do if your dog exhibited bad behavior you didn't like? Such as: chewed on your valuable items, hard to fully potty train, jumping on people, mouthing humans, hurt another pet, bite someone. *

Have you ever applied to Middletown Humane to adopt an animal? *

Yes
No

If yes, when?

Do you have any experience training a dog/puppy? *

Yes
No

Do you or have you ever used a professional dog trainer? If so, who? *

Have you ever brought animals to Middletown Humane? *

Yes
No

If yes, please explain:

Are you willing to have a representative of Middletown Humane come to see where the dog will be living? *

Yes
No

If no, please explain:

Are you willing to take responsibility of this dog for the next 10 to 15 years? *

Yes
No

What provisions will you make for the dog should you become unable to care for him/her? *

How much are you willing to spend on medical bills for your dog? *

What would you do if the vet bills went over this amount? *

Do we have your permission to view your social media accounts? *

Yes
No

Please provide two personal references (no relatives): *

Phone *

Ref #2 *

Ref Phone #2 *

Please read the following and check the box to complete the application. *

I certify the above information is true. I understand that giving false information on the application is grounds for denial of application and repossessing the dog if the application is approved. I understand the Middletown Humane Society reserves the right to deny any application.