CTTRHS Adoption Questionnaire

CTTRHS Adoption Questionnaire

CTTRHS Adoption Questionnaire

Animal Interested In ______

Name: ______DOB: ______Phone #: ______

Full Address ______Email: ______

Thank you for your interest in adopting an animal from Clermont to the Rescue humane Society. In an effort to find the best home for the animals in our care, we ask you to complete the following form. All information will be kept confidential. If you currently own dog(s), or have children, we require that you bring them in to meet the dog you are interested in adopting.

What do you consider the three most important reasons for adopting a pet?


Have you EVER been accused or convicted of any offense regarding animals? YES / NO

If yes, please explain in detail the circumstance: ______


What would you consider reasons for returning or giving up your adopted pet? ______



Do you rent or own your residence? ______Type of Dwelling? ______Length lived there? ______

If you rent, does your landlord allow pets? YES / NO

Landlord Name: ______Phone: ______(required)

Do you have a fenced yard? YES / NO If yes, type and height? ______

Where will your animal live? (circle one) Indoors mostly, Outdoors for elimination and exercise,
Outdoors mostly, Indoors on occasion OR Outdoors only


Number of people in the home: Adults:______Children:______Children’s Ages: ______

Are all members of your household in agreement about getting an animal? YES / NO

If no, why not? ______

Do any members of your household have asthma or allergies to animals? YES / NO

If yes, how will it be addressed? ______

Describe your house activity level: ______

In the event of a personal or family emergency, who would care for our pet(s)? ______


Do you currently own other pets? YES / NO

If yes, please list breeds and ages: ______


If you own dogs, are they licensed? YES / NO If not, why? ______

Where did you get your pets? (circle one) Shelter / Rescue / Friend / Stray

Are they altered? YES / NO Up to date on vaccines? YES / NO If not, why? ______

Please provide your veterinarian and their phone number (if you do not currently have one, what practice do you plan to use, or you used previously). ______

How many hours will the animal be alone during the day? ______

How will the animal be housed when no one is home? Indoors / Outdoors / Crated

Have you ever had to give a pet to a: Family Member / Shelter / Rescue / Return to Breeder / Sold / None

Have you ever had to retrieve your animal from a shelter or animal control? YES / NO

Signing this application, I am stating that I have answered all questions completely and truthfully. In the event that Clermont to the Rescue Humane Society (at any later time) discovers a falsehood, the adoption shall be annulled and the animal seized, the adoption fee will not be reimbursed. I acknowledge that I have been informed that Clermont to the Rescue Human Society has the right to deny any application.

Signature: ______Date: ______

Adoption Approved? Yes / NO If not, why ______

______Staff Member: ______