Lakeshore Humane Society

* I am interested in adopting a:

	Cat
	Dog
	Other

* Sex:

	Male
	Female
	No Preference

1st Choice Animal's Name:

2nd Choice Animal's Name:

* First Name:

* Middle Initial:

* Last Name:

Spouse or Roommates First Name:

Middle Initial:

Last Name:

* Number of Adults In Household:

* Number of Children:

Ages of children:

* Are you 18 years of age or older:

	Yes
	No

* Is anyone in your house allergic to animals:

	Yes
	No

If yes, what type of animal:

	Cat
	Dog
	Other

* Street Address:

* City:

* State:

* Zip:

* Home Phone:

Cell Phone:

* Email:

* Length of time at current address:

* I live in a:

	House
	Apartment
	Condo
	Mobile Home
	Dorm

* Own or Rent:

	Own
	Rent

If you RENT, Does your Landlord allow:

	Dogs
	Cats
	Other

Landlord Name:

Landlord Phone:

* Do you live with your parents:

	Yes
	No

* Date of Birth:

* Household Setting:

	Urban
	Suburban
	Rural

* Fenced in Yard:

	Yes
	No

How High:

* Have you ever adopted from the LHS or other animal shelters or rescues:

	Yes
	No

If yes, what type of animal:

	Cat
	Dog
	Other

* Have you ever brought an animal to this or any other shelter or rescue:

	Yes
	No

If yes, what were the circumstances:

	Surrender
	Lost or Stray
	Other

If other, please explain:

* Animal Experience:

	First Time Owner
	Knowledgeable & Experienced

* What is the activity level of your home:

	Loud
	Busy
	Active
	Quiet
	Calm
	Relaxing

Please list all current and past pets you have owned in the last five years

Pet #1

Pet Name:

Pet Breed:

Pet Age:

Sex:

	Male
	Female

Pet is current on Rabies:

	Yes
	No

Check all boxes that apply:

	Dog
	Cat
	Other
	Spayed
	Neutered
	Breeder
	Is Kept Indoors
	Is Kept Outdoors
	Is Kept In & Out
	Still Have
	No Longer Have

Reason no longer have:

	Died
	Moved
	Not Enough Time
	Bite Problems
	Landlord Issues
	Cost Too Much

Pet #2

Pet Name:

Pet Breed:

Pet Age:

Sex:

	Male
	Female

Pet is current on Rabies:

	Yes
	No

Check all boxes that apply:

	Dog
	Cat
	Other
	Spayed
	Neutered
	Breeder
	Is Kept Indoors
	Is Kept Outdoors
	Is Kept In & Out
	Still Have
	No Longer Have

Reason no longer have:

	Died
	Moved
	Not Enough Time
	Bite Problems
	Landlord Issues
	Cost Too Much

Pet #3

Pet Name:

Pet Breed:

Pet Age:

Sex:

	Male
	Female

Pet is current on Rabies:

	Yes
	No

Check all boxes that apply:

	Dog
	Cat
	Other
	Spayed
	Neutered
	Breeder
	Is Kept Indoors
	Is Kept Outdoors
	Is Kept In & Out
	Still Have
	No Longer Have

Reason no longer have:

	Died
	Moved
	Not Enough Time
	Bite Problems
	Landlord Issues
	Cost Too Much

Pet #4

Pet Name:

Pet Breed:

Pet Age:

Sex:

	Male
	Female

Pet is current on Rabies:

	Yes
	No

Check all boxes that apply:

	Dog
	Cat
	Other
	Spayed
	Neutered
	Breeder
	Is Kept Indoors
	Is Kept Outdoors
	Is Kept In & Out
	Still Have
	No Longer Have

Reason no longer have:

	Died
	Moved
	Not Enough Time
	Bite Problems
	Landlord Issues
	Cost Too Much

Veterinary Information

Veterinary Clinic:

Veterinarian Name:

Name of Person pet records are listed:

By checking this box you give your veterinary clinic permission to release pet veterinary records:

I give my veterinary clinic permission to release pet veterinary records

Small Animal Adoption Questions

Why are you considering adoption a small animal:

	Companionship
	Low Maintenance
	Fun To Watch

Where will your small animal be kept:

	Aquarium
	Wire Cage
	Outdoors
	Other

What types of small animals have you owned:

	Turtle
	Rats
	Snakes
	Mice
	Fish
	Guinea Pig
	Ferret
	Hamster
	Other

How often will your small animal be taken out of its enclosure:

	Daily
	Only To Clean Cage

What type of diet will you provide for this animal:

Dog Adoption Questions

Why are you considering adopting a dog:

	Companionship
	Exercise With Me
	Friend For My Dog
	Protection
	Hunting
	Farm Dog
	Kids Want A Pet/Gift

What Level of activity do you prefer:

	Very Active
	Somewhat Active
	Mellow

Where will your dog be primarily kept:

	Indoors As Part Of Family
	Outdoor
	Kennel

What type of exercise will you give this dog:

	Daily walk/run
	Occasional Walk
	Playtime In Yard

Approximately how many hours per day will your dog be alone:

	Less than 4
	More than 4
	8-12 or more

Where will this dog stay when you are not at home:

	Run of the house
	Confined to kennel/crate/room indoors
	Confined to kennel/tied outdoors

What of the following problems would make you return your dog to the shelter? Check all that apply

	Barking
	Health
	Housebreaking
	Too much energy
	Chewing
	Biting
	Digging
	Socialization
	Jumping the fence
	Dominance issues
	Shyness/other fears
	Other
	None. I am committed to working with my dog to correct any of these or other unanticipated problems that arise
	I plan to take my dog to obedience/training courses if necessary

Cat Adoption Questions

Why are you considering adoption a cat:

	Companion for me
	Friend for my other cat/dog
	Empty heart/cat died
	Kids want a pet

What level of activity do you prefer:

	Very Active
	Somewhat active
	Mellow
	Playful

Where will your cat be primarily kept:

	Indoors as part of family
	Outdoors
	In & outdoors

Approximately him many hours per day will your cat be alone:

	Seldom
	Less than 4
	More than 4
	8-12 or more

Do you plan to let your cat outdoors:

	Never
	Sometimes on leash or in cage
	Every night so he/she can run free

What of the following problems would make you return your cat to the shelter? Check all that apply

	Too noisy
	Too much energy
	Litter box issues
	Biting
	Jumping the fence
	Socialization
	Shyness/other fears
	Can't get along with other pets
	Health
	None. I am committed to working with my cat to correct any of these or other unanticipated problems.

* I feel all pets should be spayed or neutered:

	Yes
	No

* I fell all pets should wear collars with I.D:

	Yes
	No

* Some dogs and cats live 15+ years, and caring for an animal can be expensive. Are you willing to provide adequate food, shelter and medical care, including yearly check-ups and vaccinations for the life of your adopted pet:

	Yes
	No

* All animals need time to adjust to their new surroundings, especially when other animals are involved. Are you prepared to devote time, training, or whatever it takes to help your new pet adjust to its new surroundings:

	Yes
	No

* Children should not be solely responsible for the care of a pet. Are all family members willing to care for this pet:

	Yes
	No

* Who will care for your pet when you are away from home for an extended period of time (vacation, business, personal, etc.):

	Professional sitter
	Boarding facility
	Stay with friend/family/neighbor
	Stay alone with daily checks by others

Please provide the names and phone numbers of two NON-RELATED references

* Ref 1 Name:

* Ref 1 Phone:

* Ref 2 Name:

* Ref 2 Phone:

* Verification:

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