Application – Siskiyou Humane Society

To be considered as an adopter, you must: Be 21 years of age, have the knowledge and consent of all adults living in your household, have a valid ID with current address, have the knowledge and consent of your landlord (if applicable) and understand that the Siskiyou Humane Society must approve your application.

Name

First

Last

Phone

Email

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a different mailing address?

Yes

Mailing Address (if different from above)

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth - To be considered you must be 21 years or older.

Occupation

Please select your reason for adopting a pet:

Please explain:

Do you currently have any pets of your own?

Yes
No

If so, please provide names, types, breeds, genders, ages, spayed/neutered if indoors or outdoors, and how long you have owned them :

Are you adopting for someone else?

Yes
No

Please explain:

Are you aware the yearly vaccinations and routine preventative vet care typically costs between $80 - $200 per year?

Yes
No

Who is your Veterinarian?

How will you transport your pet home, to the vet, etc?

Have you ever adopted an animal from an animal shelter?

Yes
No

Do you plan on attending obedience classes with your dog?

Yes
No

If you drive a pick up truck, would you allow the animal to ride in the back/bed?

Yes
No
Other

Please Explain:

Previous dog owning experience (please select all that apply)

Never had a dog before
Had one or two growing up, this would be the first as an adult
Always have had one or more dogs
Always have had a particular breed or type of dog
Have experience working/volunteering with Humane Societies/animal welfare organizations
Have titled/certified dog in sports or activities
Have participated in obedience and/or puppy classes

Typical time away from home during the work week:

Please Explain:

If you are gone during the day, is someone else home?

Yes
No

Is that person willing and able to be responsible for looking after the dog?

Yes
No
Maybe

Mark all that describe your lifestyle

Working during the week, relax on the weekends
Very active, daily outdoor exercise (hiking, walking, sports, etc)
Working during the week, active on weekends
Dedicated couch potato/sedate lifestyle
Can take dog to work regularly
Mostly home, prefer to stay there

Is your yard fully fenced

Yes
No
Partially fenced

Describe your fence - type of fence and height

Where do you plan to leave the dog when you are not home?

Please Explain:

Where will your dog sleep at night?

Please Explain:

How do you plan to exercise your new dog?

Please Explain:

List any adults that will be living in the household with the pet. Please include age and relationship to each person listed:

List any children that will be living in the household with the pet. Please include age to each person listed:

Are you aware that a new environment is stressful for your pet, and they may exhibit uncharacteristic behavior?

Are there any persons who regularly visit the home (grandchildren, family members, etc)? Explain and list visitor(s) ages below.

Does anyone in your home have allergies to dogs or have asthma?

Yes
No

List any animals that will be living in the household with the pet. Please include age, species and gender:

How did you hear about us?

Please Explain

Would you like to join our mailing list?

Yes
No

Would you object to an authorized representative of the SHS inspecting the animal and the house/home where the animal is kept?

Yes
No

Have you ever been convicted of a crime that involved an animal(s)?

Yes
No

By typing my full name below, I am certifying that all the above information is true and accurate. I also understand that a giving false information on this application is grounds for denying my application.

ADOPTION CENTER: OPEN MONDAY - SUNDAY 12:30-4:00pm

ADOPTION CENTER: OPEN MONDAY - SUNDAY 12:30-4:00pm

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