SMALL ANIMAL Adoption Application If you are interested in applying to adopt a SMALL OR BARNYARD ANIMAL, please fill out the form below. Adoption Application: SMALL ANIMAL/BARNYARD Step 1 of 3 33% Which animal(s) are you applying for today? PERSONAL INFORMATIONName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Cell NumberWork NumberEmail* Date of Birth* MM slash DD slash YYYY Occupation* HOUSEHOLD & LIFESTYLE INFORMATIONWho will be primarily responsible for the care of this animal?* Do you plan on breeding this animal?* Yes No Maybe Are you willing to give the animal at least 6 weeks to adjust to its new environment?* Yes No Do you agree to take your adopted animal to a vet within 7 days of adoption? (ferrets & bunnies only)* Yes No Do you understand that your adopted animal may require additional veterinary care as a result of being exposed to shelter related illnesses (i.e. upper respiratory infection or coccidia)?* Yes No Would you be willing to make a donation to help the other homeless animals of HSHC?* Yes No Please list all your current pets and all the pets you have had in the past 5 years: (use the (+) symbol to add additional lines)*Pet’s NameSpeciesBreedAgeSexSpayed or Neutered? (Yes or No)If you no longer have this pet, where are they now? I understand that the falsification or omission of any of the above information will result in automatic refusal of adoption or confiscation of the adopted animal. I authorize HSHC to verify the validity of any information contained in this application. I hereby agree to release, discharge, indemnify and hold harmless the Humane Society of Harford County and any of its agents from any and all liabilities that may arise out of the handling by me and/or my party.Consent* I agree to the application policySignature* Date* MM slash DD slash YYYY CAPTCHA