Adoption Application
P.O. Box 458 Monterey, VA 24465 540.908.9152
www.highlandcountyhumanesociety.org
info@highlandcountyhumanesociety.org
What animal are you interested in? Name: _______________________________
______dog ______cat
Tell us about you:
Name: _______________________________________________________________________________
Street Address: ________________________________________________________________________
Mailing Address: ______________________________________________________________________
City: _____________________________________________State: _____________Zip code: __________
Home Phone: _________________________________Cell Phone: _______________________________
Work Phone: _________________________________
Email Address: ________________________________________________________________________
Do you ____Rent____Own____Live with parents____Live on campus ____Other? explain: ___________
Do you live in a
____House_____Townhome_____Apartment ____Mobile Home______Other?
How long have you resided at this address? _________________________________________________
If you rent, please provide leasing company information, name and telephone contact:
_____________________________________________________________________________________
How many adults live in your household? ______How many children live in your household? _________
Ages of children in household: ____________________________________________________________
Is anyone in the household allergic to animals? __________Who? _______________________________
Is anyone home during the day? _______If Yes, Who? _________________________________________
How many hours will this pet be alone during the day? ________________________________________
Who will be responsible for caring for this pet? ______________________________________________
Do you have a fenced yard? ___________Type of fence? _______________________________________
Is the fence attached to the house and enclosed? ___________________________________________
If you’re interested in a dog, how will you exercise it? _________________________________________
How often?___________________________________________________________________________
Please describe the areas where the dog would get exercise: ____________________________________
Where will this pet be kept during the day?__________________________________________________
Where will this pet be kept at night?_______________________________________________________
Who will care for this animal when you go on vacation? _______________________________________
Have you ever re-homed or given up a dog or cat to an animal shelter, SPCA, or pound?______________
If yes, please explain: ___________________________________________________________________
Tell us about your vet: Name of your Vet: __________________________________________________
Name & Location of Vet Hospital: _________________________________________________________
Telephone # of your Vet: ________________________________________________________________
List the other pets currently in the household:
Name
Breed
Sex
Age
Are all current pets spayed/neutered? _________ Are all pets current on Rabies vaccines? ____________
References: Please provide 3 references not related and not living with you:
Reference Names and contact info:
_____________________________________________________________________________________
____________________________ ________________________________________________________
_____________________________________________________________________________________
Have you or anyone in your household been convicted of animal cruelty, neglect, or abandonment? ____
If yes, please explain: ___________________________________________________________________
How did you hear about us? Web search Online Adoption site (which one? ______________) Radio ad
Newspaper ad Flyer Other, please describe: ________________________________________________________
I understand that adopting this pet is a lifetime commitment. I am willing and able to care for this animal by providing personal
attention, veterinary care, proper nutrition, grooming, training, and exercise. I understand that human interaction, socialization,
and bonding are important to the wellbeing of this adopted animal. I certify that the all of the information provided above is correct
and I understand that the Highland County Humane Society has the right to verify this information. All adoption decisions are made
by the Adoption Committee after very careful review and thorough investigation. The details of this decision are confidential and not
accessible by administrative volunteers. I agree to a home visit if requested by Highland County Humane Society.
I certify that I, nor anyone in my household, has not been convicted of any charges pertaining to section 3.1-796.122 under Virginia
code regarding the cruelty to, neglect or abandonment of animals.
Signature________________________________________________Date:__________________
*considered signed when submitted electronically