EmailMe Form - SCOTT COUNTY DOG ADOPTION QUESTIONNAIRE

EmailMeForm

Dog's Name You Are Interested In Adopting:
Name *
First Last
Date Time *
MM / DD / YYYY
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Home Phone *
### - ### - ####
Date of Birth (mm/dd/yy) *
Email
Employment Status
Employed
Retired
Unemployed
Other
Name of Employer
Work Phone
### - ### - ####
Thank you for considering adopting an orphan from our shelter. You will be making a 10-15 year commitment to the dog you adopt and our goal is to help make the best match possible for you and the orphaned dog you are interested in. The following questions will help us achieve that goal.
Do you currently live in a *
House
Apartment
Condo
Other
If other, please specify:
Do you currently *
Rent
Own
Lease the residence where you live
How long have you lived at your current residence? *
If not a property owner, Humane Society of Scott County, Indiana has my permission to verify current pet policy:
Yes
No
Landlord's Name
First Last
Landlord's Phone
### - ### - ####
How many adults live in your home? *
How many children live in your home? *
What are the ages of the children in your home? *
Does anyone in your household have allergies? *
Yes
No
Who will be primarily responsible for the care of this dog? *
Is this dog a gift? *
Yes
No
If yes, for whom?
What size dog are you looking for? *
Small
Medium
Large
Extra Large
What attracted you to the dog you are interested in? *
Which of the following best desribes your reasons for wanting this dog? (Check all that apply) *
Companion
Guard Dog
Hunting
Breeding
Obedience Training
Search & Rescue
Agility
Jogging/Walking Buddy
Couch Warmer
How many hours will the dog be alone each day? *
Where will the dog sleep at night? *
Where will the dog be kept when no one is home? *
Do you have a fenced yard? *
Yes
No
How high is your fence? *
Please list all pets you have had in the last 10 years including current pets and those you no longer own.

Breed Age Sex Spayed/Neutered Owned how long? Is the pet still with you? If not, why?
If you have other pets, are their vaccinations current?
Yes
No
If you have other pets, are they currently licensed?
Yes
No
Do you have a regular veterinarian?
Yes
No
Veterinarian Name
First Last
Veterinarian Phone
### - ### - ####
Under what circumstances would you NOT keep this dog? *
How much do expect to spend per year to care for this dog (vet, supplies, food, toys)? *
Please check the topics you would like our staff to discuss with you today: *
House Training
Indoor vs. Outdoor
Separation Anxiety
Chewing
Introduction to Other Pets
Crate Training
Vaccines
Vacation With/Without Pets
Exercise Requirements
Animal Laws
Dogs & Kids
Escaping
We will review application and call you within 48 hours of receiving it.
Thank you for considering one of our orphans for adoption. Our goal is to help make the best possible match for you and the pet you are interested in.

Again, thank you for choosing one of our furbabies.
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BELOW IS FOR INTERNAL USE ONLY
Case Number:
Date:
Review by:

Breed	Age	Sex	Spayed/Neutered	Owned how long?	Is the pet still with you? If not, why?

Thank you for considering adopting an orphan from our shelter. You will be making a 10-15 year commitment to the dog you adopt and our goal is to help make the best match possible for you and the orphaned dog you are interested in. The following questions will help us achieve that goal.

We will review application and call you within 48 hours of receiving it.