Adoption Form - Dogs - Pembina Valley Humane Society

Name of Dog Interested In*

Full Name*

Email Address*

Address*

(if rural, list both physical & mailing address)

City/Town/RM*

Province*

Postal Code*

Phone Number*

Alt Phone Number

Preferred Contact Method*

Phone

Best time of day to reach*

Are you 18 yrs of age or older?*

Yes

Full names of all adults who reside in the residence:*

List the ages of all children under 18 yrs:*

Does anyone in the home have allergies to pets?*

Yes

Did all household members participate in this decision?*

Yes

Who will be primarily responsible for the care of your new dog (feeding, grooming, exercising, training)?*

Why do you want to adopt?*

Other*

Do you live in a:*

Other*

For how long?*

Do you:

Own

Rent

Live with Parents

Other

Other*

What qualities are important to you for your next dog?*

(example: calm, housetrained, athletic, affectionate, good with cats/kids/dogs, etc.)

How much and what type of exercise will your dog be provided?*

How much time will the dog be alone?*

Your dog will be kept:*

Indoors

Outdoors

Barn

Garage

Where will the dog sleep at night?*

Indoors

Outdoors

If your dog will be kept mainly outdoors, please describe accommodations for the dog.*

Type of confinement:*

Fully fenced yard

Dog Run

Tied up

Crate or Kennel

Loose on Property

Undecided

Yard (ht):*

How/where will the dog receive exercise?*

How often?*

How many pets have you had in the last 5 years?*

(Dogs, Cats, Other)

How many pets do you currently live with?*

(Dogs, Cats, Other)

What breed of dog(s)/cat(s) do you have?*

How old are your current dog(s)/cat(s)?*

What types of training methods are you looking to use with your dog?*

Are your pets spayed/neutered?*

Yes

If not, why?*

Are your pets up to date on vaccines?*

Yes

If not, why?*

Which veterinary clinic would have past or present records?*

Which veterinary clinic will you take your new pet to?*

Have you ever had to return or re-home a pet? If so, why?*

A dog can live well over 10 years and requires a major amount of time, exercise, finances and emotional stimulation. Do you feel you can make that kind of long-term commitment at this time?*

Yes

Please check off all areas you would like to discuss with the shelter manager:*

Introducing new dog to other pets

Kids & Dogs/Puppies

Housetraining

Diet/Nutrition

Obedience Training

Proper Socialization

Toys/Enrichment

Pet Identification

Kennel/Crate Training

Reference 1

*Only 1 reference can be a relative & that relative must not live with you. All references must be 18 years of age or older.*

**If references do not call back within 72 hours of initial contact we will move on to the next applicant**

Name*

Relationship*

Contact Phone #*

Email Address*

Best time of day to be reached*

Reference 2

Name*

Relationship*

Contact Phone #*

Email Address*

Best time of day to be reached*

Veterinarian

Name*

Contact Phone #*

Contact Phone #

Best time of day to be reached*

Landlord (if not applicable, enter N/A in following fields)

Name*

Contact Phone #*

Email Address*

Best time of day to be reached

I certify that the information given on this form is true and correct and I recognize that any misrepresentation of facts will result in my being unable to adopt a pet from PVHS. I understand that submission of this application does not guarantee adoption and that approval or denial of this application is at the sole discretion of PVHS.

Comments

This field is for validation purposes and should be left unchanged.

Adoption Form – Dogs

Reference 1

Reference 2

Veterinarian

Landlord (if not applicable, enter N/A in following fields)