Adoption Questionnaire Please take a few minutes to answer our questions so we can assist you in finding the best pet for your home and family. Step 1 of 2 50% Date* MM slash DD slash YYYY 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 PhoneEmail* Date of Birth* MM slash DD slash YYYY HOUSEHOLD INFORMATIONWhere do you live?* Townhouse Apartment or Condo Single Family Home Mobile Home HSHC welcomes adopters who rent, or who live in an apartment or condo. Please be aware, some landlords and management companies have breed and/or weight restrictions, limits on number of pets, and may require pet deposits or pet rent. Tell us about members of your household (names and ages):*Tell us about the pets in your home (name/species/age):*Do you have a fenced yard Yes No How long will your pet be left alone? What are you looking for in a new pet? (Check all that apply):* High energy Low-to-Medium Energy Cuddles Playful Good with dogs/cats Couch potato Have you ever had to give an animal away?* Yes No If yes, what were the circumstances? Check any additional topics you would like to discuss: Feeding Finding a veterinarian Finding a trainer Moving with pets Flea/tick prevention Heartworm prevention Check any extra services and opportunities you are interested in: Borrowing a crate Low-cost vaccines/microchip for current pet(s) Low-cost spay/neuter for current pet(s) Volunteering Fostering Making a monetary or in-kind donation Is there anything else you would like to tell us to help us match you with a pet?*Are you a first responder, active military, or a veteran?* Yes No How did you hear about us?* TV Radio Newspaper Social media Special event CAPTCHA
