ADOPTION APPLICATION
ID#
Animal’s Name
Current Date
P/U Date
(Making a 10 – 20 year Commitment)
Humane Society of Wayne County
PLEASE PRINT
Last name
Address:
Phone #s: Home: (
Place of Employment:
Work Phone #: (
First Name
City:
)
MI
State:
Cell:
)
(
Zip:
)

Is it OK to Call at Work? Check box if yes.
Are you 18 years of age or older? Check box if yes. 
If not 18 or older, parent’s/guardian’s signature witnessed by a HSWC staff member is required below:
Parent’s/Guardian’s Signature:
Date:
Household composition: # Adults?
Childrens’ Ages
# Children?
Does anyone in the household suffer from allergies to animals? Check box if yes.
Do you OWN your house? Check box if yes.



If yes, skip to “Why do you want to adopt an animal?”
Do you OWN a mobile home? Check box if yes. 
f yes, skip to “Why do you want to adopt an animal?”
If in a mobile home park, park owner’s name:
Park owner’s phone #: (
)
For RENTORS: Rental agent’s’s name:
Rental agent’s phone #: (
)
Is a security deposit required? Check box if yes.

Is there an additional monthly rental fee? Check box if yes.
Why do you want to adopt an animal?
If adopting a CAT, will this cat live inside? Check box if yes.
If adopting a DOG, will this dog live inside? Check box if yes.
How will the dog be confined outside?
How will the dog get exercise?
What would you do with the animal if you moved?
How did you hear about us?
Internet site (which one?)
Adoption Application-Rev. 3
Effective 05/07/11
Word of mouth




Flyer

Radio/TV
Other

Print media
Page 1 of 2

PLEASE LIST ALL CATS AND DOGS YOU HAVE OWNED IN THE PAST 5 YEARS
If no longer in the household, what
Pet’s Name
Dog/Cat
Breed
Age Sex Altered? happened to the pet?
Is your pet(s) vaccinated against rabies? Check box if yes.

Is your pet(s) vaccinated against distemper? Check box if yes.

If CAT(S) in the household:
Have your cat(s) been tested for feline leukemia (FeLV)? Check box if yes.
Have your cat(s) been tested for feline “AIDS’ (FIV)? Check box if yes.


For food and vet care, are you prepared to spend about $300 per cat per year? Check box if yes.
If DOG(S) in the household:
Do you give your dog(s) heartworm prevention medicine? Check box if yes.
Is your dog(s) licensed? Check box if yes.




For food and vet care, are you prepared to spend about $600 per dog per year? Check box if yes.
What vet hospital(s) do you use?
Hospital Phone #: (
)
What name are the vet records under at the vet hospital?
If you wish to receive updates about shelter activities and information about animals and animal care, please
PRINT your e-mail address
 I understand that falsification or omission of any of the above information will result in an automatic
application denial.
 I authorize the release of my name and information for the exclusive use of Hills Science Diet so that I
may receive promotional discounts, coupons, and other information from them.
o Do not release my information to Hills Science Diet

 I give permission to my vet hospital to release any records pertaining to my animals or animals that I
have owned to the HSWC for the purpose of processing my application.
Signature:
Date:
The Humane Society of Wayne County reserves the right to deny this application.
FOR HUMANE SOCIETY USE ONLY
Adoption fee
S/N Deposit
Total
Driver’s License #
 Approved  Denied
Adoption Application-Rev. 3
Effective 05/07/11
By whom?
________ HSWC tag # ________
Page 2 of 2
Release, Waiver, and Disclosure Agreement
I, the undersigned, do:
 declare I am aware:
o that animals are different from human beings in their response to human action.
o that actions of animals are often unpredictable.
o that the HSWC makes no claims or guarantees regarding the behavior, health, or temperament of animals put up
for adoption.
 hereby adopt this animal in its present condition and agree to care for it in the most humane manner.
 promise not to use this animal for vivisection, breeding, or in any inhumane way.
 agree to have this animal spayed or neutered and vaccinated against rabies, if applicable in accordance with HSWC
policies and New York State Laws.
 agree that in the event I can no longer care for this animal, I will return it to the HSWC SHELTER in Lyons, NY.
 understand the transfer of this animal from the HSWC to me depends upon my compliance with these promises and
that if I do not comply with this agreement, the HSWC may repossess the animal from me upon demand.
Liquid Damages Agreement
1. I, the adopter, agree to pay the HSWC the sum of $150.00 as liquidated damages in the event I breach the terms of
this adoption contract.
2. I, the adopter, agree to pay reasonable attorney’s fees and court costs in the event this matter is forwarded to an
attorney for enforcement
Return/Refund Policy
I, the undersigned, do understand that:
 only authorized personnel may grant a refund of the adoption fee and/or the spay/neuter deposit within seven (7)
days of adoption.
 a spay/neuter deposit may be refunded only if the animal is returned prior to the required spay/neuter date
indicated on the contract.
 a refund is granted only if the adopter has utilized the free health examination certificate within seven (7) days of
adoption and a licensed veterinarian has determined that:
o a mistake was made by the HSWC as to the sex or surgical alteration of that animal.
o the animal has a viral infection and I must wait a sufficient amount of time before adopting another animal of
that species to assure the virus is not transferred to the new animal (consult your vet).
 medical expenses will not be reimbursed: I agree to return a sick animal to the HSWC.
 if a family member develops allergies and I present a doctor’s certificate within seven (7) days of the adoption, a
refund may be granted.
 all paperwork must be submitted with the return of the animal.
 all refunds, if granted, will be paid by check and mailed within 10-14 days.
I, the undersigned, do agree to all conditions stated above and hereby accept possession and title of this animal
identified as ID # ________________ at my own risk, and do hereby release and waive any right against the
HSWC for any damages to persons or property caused by said animal.
Signature:
Date:
(over)
Release, Waiver, and Disclosure Agreement Form-Rev. 1
Effective 05/03/06
Page 1 of 1
HUMANE SOCIETY OF WAYNE COUNTY
1475 County House Road
Lyons, NY 14489
Telephone (315) 946-3389
Fax (315) 946-9132
E-mail – HumaneSocietyWayneCounty@verizon.net
Routine Vaccinations and Treatments for Shelter Animals Prior to Adoption
When old enough, HSWC uses a SNAP 3Dx® test to test all our dogs for heartworms, Lyme disease, and
Ehrlichiosis and a SNAP® FeLV test to evaluate all our cats for feline leukemia (FeLV). Only animals that test
negative are adoptable by the public. However, the viral incubation period for FeLV is sufficiently lengthy so a
single test may not detect this virus. In addition, heartworm exposure is detectable only after approximately six
(6) months from infection date. Follow the advice of your veterinarian about retesting the cat/dog.
A veterinarian administers a one (1)-year rabies vaccination to all animals older than three (3) months as
required by New York State law.
All dogs are given an Intra-Trac3® intra-nasal vaccine against bordetella (kennel cough). Cats and dogs are
vaccinated against the common illnesses using HCPCh vaccine for cats and DAPPvL2 vaccine for dogs (older
than six (6) weeks). Animals younger than six (6) months of age require at least two (2) vaccinations four (4)
weeks apart to build up their immunity. All dogs older than six (6) months are temperament-tested.
In addition, all animals are treated for roundworms and hookworms using at least two (2) doses of Strongid
wormer two (2) weeks apart to interrupt the reproductive cycle of the worms. Due to the cost of the
medications, HSWC treats animals for whipworms, tapeworms, and coccidia only if a fecal examination detects
the presence of these worms/protozoa. A fecal exam does not always detect the presence of worms/protozoa.
If detected, ear mites are eliminated by cleaning the ears and administering a series of three (3) ivermectin
injections two (2) weeks apart. However, additional treatments may be needed. Fleas, if present, are eliminated
using a single treatment of Advantage.
If an animal is adopted prior to receiving the required vaccinations and treatments, it is your responsibility to
complete the treatment protocol. Your veterinarian will recommend a course of action to assure the good health
of this animal.
I UNDERSTAND THAT HSWC WILL NOT REIMBURSE ME FOR ANY COSTS INCURRED WHEN
I USE THE FREE HEALTH EXAM AT A PARTICIPATING VETERINARIAN.
Signature of Adopter:
Routine Animal Vaccinations and Treatments Rev. 5
Effective 05/05/12
Date:
Page 1 of 1