Applicant To Keep First Page Adoption Questionnaire Over 60% of the 3200 + animals we received last year were turned in by their owners. We want you to adopt an animal from us, but we want you to understand what you are getting into. 1. We check your background to ensure that are our animals are placed in the best home possible. 2. If you rent your home, live in a trailer, or are part of an association we may call your landlord. We do this as a courtesy since there are many breed restrictions and pet deposits worked into contracts. We want you to be aware of any additional costs. 3. Everyone wanting to adopt will be screened in our database for pet neglect and abuse. 4. We want to help you save a pet through adoption, but we do reserve the right to refuse anyone. We ask that you have the experience, patience, and resources to stick with an animal that may have problems due to a difficult background or adolescence. We want this dog or cat to stay with you and your family, that s why we are here, and why we care so much about them. SUMMER HOURS: Mon 1 pm 7 pm / Tue 1 pm 7 pm / Thu 1 pm 8 pm / Fri 1 pm 7 pm / Sat 12 pm 6 pm WINTER HOURS: Mon 1 pm 6 pm / Tue 1 pm 6 pm / Thu 1 pm 7 pm / Fri 1 pm 6 pm / Sat 12 pm 5 pm We are always closed on Wednesday and Sundays. 7811 60 th Ave, Kenosha, WI 53142 P: (262)694-4047 F: (262)694-1956 www.safeharborhumanesociety.org
Office Supplies Copy paper (8 1/2 X 11) white and colored Letter size file folders (manila) 2 pocket colored folders Sharpies Post It notes Shelter Supplies Bleach Hand Sanitizer Liquid Laundry detergent Paper towels Dish soap Toilet paper 13 & 33 gallon trash bags Contractor trash bags Kleenex Our Wish List Items listed in order of need. Pet Supplies Canned kitten food(always needed) Canned cat food Kitten & puppy food Cat litter (least expensive non-clumping) Dry cat food Dry dog food Scrub sets (tops or bottoms) Carriers and crates Small animal supplies & food Durable dog chew toys Other Donations Cash donations are always needed! Gift cards for Petco, Petsmart, Walmart, Office Max, Speedway, etc. Gas cards Postage stamps Leftover/spare knitting and crochet type yarn and batting/pillow stuffing Things to Avoid Donating Thanks to the wonderful generosity and support of our community we are not in need of the following items at this time. Our storage space is limited. Towels Blankets Newspaper
Adoption Questionnaire In order to qualify as an adopter, you must: Be 18 years or older and hold a valid state ID Provide all information requested on this application. Have consent of all adults in household. Understand all adults in your household are subject to criminal background checks. Be able and willing to spend time to ensure a stable environment and the financial resources necessary to provide training, medical treatment, proper care for your pet and a forever home. Understand that Safe Harbor Humane Society reserves the right to refuse any adoption for any reason. Please answer the following questions: Choice #1 Dog Cat Name/ID# General Interest: Dog Cat Choice #2 Dog Cat Name/ID# Size: Age range: Choice #3 Dog Cat Name/ID# Breed: How many adults in Household? How many children? Children s Ages: Adult #1 First Name: Middle Initial: Last: List any names or nicknames previously used: Address: #: City: State: ZIP: Phone: Cell # Email: Your occupation: Company Name: Business telephone: Length of employment: DOB: Adult #2 First Name: Middle Initial: Last: List any names or nicknames previously used: Your occupation: Company Name: Phone: Length of employment: DOB: Adult #3 First Name: Middle Initial: Last: Your occupation: Company Name: Business telephone: Length of employment: DOB: Please note any additional adults on the end of the form.
Do you live in a: House Condo Apartment Mobile Home Townhouse Other Do you? Own your home Rent Live with parents Other Please provide any additional information (unit/lot number or letter, upper or lower) Do you live with parents? Yes No If yes, do your parents: Own their home Rent If you rent, live in a trailer park or are part of an association: Association or Landlord s name: Phone No. ** Application will not be processed without the landlord s, association, or park information ** How long have you lived at your current address? Years Months Who will be primarily responsible for the animal? You Kids Entire Family Other It may take your pet a month or longer to adjust to its new environment. Are you willing to allow this much time for adjustment? Yes No Do you agree to return the pet to the adopting agency (SHHS) if you can no longer keep it? Yes No Have you ever adopted from any humane society or rescue in the past? Yes No If yes, when and what shelter? Have you ever released one of your own animals to a shelter? Yes No If yes, please explain To what shelter: Year: How much are you willing to spend yearly for the care of your adopted animal? Please keep in mind that some of our animals have unknown medical history and may require veterinary care. (Food, medical care, boarding, toys, etc.): $0-$200 $200-$500 $500-$1000 $1000+ If adopting a CAT: Why are you adopting a cat? Where will your cat be kept during the day? Where will your cat be kept in the evening? Where will your cat sleep at night? Will your cat be allowed outside? Yes No What is your opinion of de-clawing cats?
Why are you adopting a dog? If adopting a DOG: Where will your dog be kept during the day? Where will your dog be kept in the evening? Where will your dog sleep at night? Do you have a completely fenced in yard? If you do not have a fenced in yard, how will the dog go outside? Taken for walk Tied up Other Outside Kennel How will you housebreak your dog? If necessary, before you bring this animal back for behavioral issues, are you willing to consider: Crate training? Yes No Obedience training? Yes No On average, how many hours will the dog be left alone during the day? During the evening? Do you currently own any dogs, cats or other pets? Yes No If yes, please list: Pet I Pet 2 Pet 3 Pet 4 Name: Name: Name: Name: Cat Dog Cat Dog Cat Dog Cat Dog Breed Breed Breed Breed Age Sex: M F Age Sex: M F Age Sex: M F Age Sex: M F Neutered/Spayed: Y N Neutered/Spayed: Y N Neutered/Spayed: Y N Neutered/Spayed: Y N Years Owned: Years Owned: Years Owned: Years Owned: Please provide your current veterinarian information: Name: City: State: Phone: Under what name are your vet records kept? As given at the top of application Other: Will you be using the same veterinarian for your new pet? Yes No If not, which veterinarian will you be using? As the adopter, you will be responsible for providing adequate care for your animal, which will be determined by your veterinarian. If this animal becomes ill, I certify that I am financially and/or emotionally prepared to treat this animal at my own expense. Initials:
Terms of Agreement I certify that the information provided on this application is true, and I recognize that any falsification of information requested may result in losing adoption privileges. I authorize investigation of all statements in this application and understand veterinarians, other humane agencies, landlords, or other outside sources may be contacted. I understand that the adoption of an animal may be delayed until such information can be verified. Upon submitting this application, it becomes sole property of the Safe Harbor Humane Society. The information in this document is confidential and will be kept in the strictest confidence of the staff at Safe Harbor Humane Society. Safe Harbor Humane Society reserves the right to deny adoption to anyone based upon this application and/or investigation of additional information for any reason. I understand that Safe Harbor Humane Society makes decisions in the best interest of the animal. As a Safe Harbor Humane Society adoption applicant, I understand that I will be interacting with and handling animals. I understand that in handling animals I may undertake any number of risks. I understand that in assuming this I may be exposing myself to potentially significant health risks or serious medical conditions, including, but not limited to: injuries from bites and scratches, slips or falls, infectious diseases, parasites, and allergic reactions (e.g. rabies, fleas, ringworm, allergies, and asthma). Since many animals that come to the SHHS are from unknown backgrounds and are therefore ultimately unpredictable, I am thus aware that Safe Harbor Humane Society is not in a position to know and makes no representations with the temperament, health or condition of any animal in particular. I must rely on my own judgment and I understand and agree that by handling the animal, as an applicant I do so at my own risk. Therefore, I agree to hold harmless, the SHHS, its employees, volunteers, agents, or directors, whether collectively or individually, for any injury or liability the animal(s) may cause to me. I further assume any and all liability for damages or to other persons, which may be caused by any animal(s) while in my care as an applicant, and hold the Safe Harbor Humane Society harmless therefrom. Print Name: Date: / / Signature: Time: : AM/PM Office Use Only Below ASSR: Pet Deposit?: Weight or Breed Restrictions?: CCAP: DNA/SURR: PP: Staff Approver: Date/Time: