Perry County Humane Society

A private, not-for-profit charitable corporation - not affiliated with any office or agency of the Perry County, Ohio, government
P.O. Box 105

New Lexington, Ohio 43764



Adoption Application



PLEASE NOTE: A submitted application does not guarantee adoption of a dog from PCHS; nor that the dog an applicant would like to adopt from PCHS is the one that is best suited to meet their needs, and PCHS reserves the right to offer one they feel is better suited to match the application.



Name of Applicant/Dog's Primary Caregiver: ______________________________________



Spouse/Parent/Co-Applicant Name: _____________________________________________



Mailing Address: ________________________________________________________________________________



Street Address, city, state & zip (if different from above):_______________________________________________________



Daytime phone: ___________ Evening phone: ______________ Best time to contact: _________



Fax: ______________________ email ________________________________________________



How many adults in the home?: _____ How many children in the home?: _______ Ages?: ________



List any Step-Children, grandchildren, cousins, friends children and their age(s), that visit week-ends or vacations:



______________________________________________________________________________________



Are you aware that a dog can easily injure or knock down a child and/or the elderly? yes____ no______



Is there anyone at home who may be adversely affected by a dog? (allergies, etc.): yes _____ no _____



Have you owned a dog before? yes______no________ Do all family members want this dog? yes ____no___



Who will be responsible for the care of this pet?: ____________________________________________



How did you find us? Past Adopter____ Veterinarian _____ Shelter/Humane Society ____ Internet ____



Have you applied to another group for a dog? yes___ no___



If yes, which group(s): ____________________________ Approximate date ________________



May we (or our representative) visit you at your home, prior to adoption? Yes____ No______



Would you consider a senior dog? (i.e. one who required medication for a permanent but controlled condition, or one who blind, deaf etc?)) yes____ no____



Preferred age: puppy____ young adult____ older adult____ senior____ no preference_____



Activity Level: High___ Medium___ Low___



Preferred sex: male___ female_____ no preference____



*The use of the term adoption in this Application and elsewhere by PCHS is not intended to guarantee nor imply that the terms, rights, responsibilities or other circumstances of this transaction are similar to the adoption of a child. Under Ohio law, all types of dogs are considered personal property. However, this transaction is NOT a sale, gift, nor a lease of the dog. All dogs remain the exclusive property of PCHS and must be returned to PCHS immediately upon request. There is a fine of $500 for failure to comply.



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The Perry County Humane Society, Inc., (PCHS) - Adoption Application (page 2)



Do you live in a: House___ Townhouse/Condo____ Apartment___ Duplex____ Trailer____ Other___



How long have your lived at your current address? ______ Do you: Own____ Rent____



Do you have the landlords permission to have a dog ? yes____ no____



If you rent, your landlord's name/address/phone (phone number MUST be provided):



____________________________________________________/phone #_________________________



*Please give the name and phone number of the veterinarian you plan to use:



____________________________________________________/phone #_________________________



____________________________________________________/phone #_________________________



____________________________________________________/phone #_________________________



*Please list all veterinarians you have used in the past 3 years (including phone numbers). Please notify

your vet that we may call and that you give your permission for us to check on past care of your animals.



____________________________________________________/phone #_________________________



____________________________________________________/phone #_________________________



____________________________________________________/phone #_________________________



Please list all of the pets you've had in the past 5 years (type, sex, age, spayed/neutered, where is it now?):



______________________________________________________________________________________



______________________________________________________________________________________



If you have had a pet die due to: age, illness, euthanasia, accident, in the last 5 years -- please give details:



______________________________________________________________________________________



______________________________________________________________________________________



Have any of your pets ever been treated for heartworms? yes___ no___ If yes please explain:



______________________________________________________________________________________



Are all dogs presently living with you on regular heartworm prevention? ____ yes ____ no



Please list type of medication; how often give; if not on preventative, please explain why:



______________________________________________________________________________________



*Please give the names and phone numbers of two references:



____________________________________________________/phone #_________________________



____________________________________________________/phone #_________________________



*By signing this Application, you grant PCHS permission to check your vet references as well as your personal references.



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The Perry County Humane Society, Inc., (PCHS) - Adoption Application (page 3)





Are you familiar with the use of a dog crate to train and/or confine the dog in your absence? yes ___ no___



Are you willing to use a crate? yes ____ no ____



How many hours a day will the pet be left alone? ___________________



Where will pet be kept during the day? Be specific: _________________________________



Where will pet be kept at night? ________________________________________________



Is there anyone home during the day? yes ____ no____



Do you have a fenced in yard?: yes ____ no ____



Type of Fence: ________________ Height of Fence: ____________



Will your dog be tied outside? yes____ no_____



Will your dog live in the yard? yes_____ no______



If you do not have a fenced yard? How will you exercise the dog? _____________________



Will your dog be allowed to run free? (off your property) Yes ___ No___



Will your dog be allowed in the house? Yes ___ No___



Will your dog be blocked off from certain portions of the house? yes___ no ____



Will your dog receive formal obedience training? Yes ___ No___



Have you ever trained a dog before? Yes___ No___



Are your aware that some dogs may shed all year long? Yes___ No___



Will you groom the dog yourself or use a groomer? self____ groomer____ both____



Are you aware that routine costs of maintaining a dog averages ~$800-$1000 per year Yes___ No___



In the event you are unable to care for this pet in the future, who will be responsible for its care for the balance of its life?



____________________________________________________/phone #_________________________



Will rescue be notified? yes_______ no__________



Do you understand and agree that the dog you adopt from PCHS remains the property of PCHS at all times, and that the dog must be returned to PCHS (or its appointed agent) by the adopter upon PCHSs written notice to the adopter at the residence of the dog. Yes _____ No____



Do you understand and agree that you will not place or transfer the dog you adopt from PCHS into any home other than your own, and that you will return the dog to PCHS if you are no longer willing or able to care for it? Yes _____ No____



Have you sold, given away, or surrendered a pet to a shelter? Yes _____ No____



If yes, please explain: ______________________________________________________________________________________



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The Perry County Humane Society, Inc., (PCHS) - Adoption Application (page 4)







Who will care for this pet while you are on vacation?: ________________________________



If you move, what will you do with this pet? ______________________________________



Are you willing to take responsibility for this pet for 10 years or more of its life? yes____ no____



Please tell us why you want a dog_________________________________________________________________________



____________________________________________________________________________________________________



Do you have any special needs or wants? ____________________________________________________



______________________________________________________________________________________



Please feel free to add any other information that you think might be helpful to us in evaluating your application:



______________________________________________________________________________________



______________________________________________________________________________________





Thank you for taking the time to complete or download our adoption application -- if you wish to pursue an application with PCHS, please mail your completed application, together with a $25 application fee* to:



Perry County Humane Society

A private, not-for-profit charitable corporation - not affiliated with any office or agency of the Perry County, Ohio, government

P.O. Box 105

New Lexington, Ohio 43764



Your application will not be processed until we receive this fee.



We will respond to your application as soon as possible; please remember that this organization is staffed totally by volunteers!



*Application fee - Please see Adoption Policy and please read the Adoption Contract you will be required to sign at the time of adoption.





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