First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone*

Are all adult household members ready to adopt?*
Choose one: Yes No

Do you have any work trips, overnights, or vacations that would prevent you from adopting within the next 10 days?*
Choose one: Yes No

Have you ever adopted a rescue animal before?*
Choose one: Yes No

Name and Age of primary caregiver for the animal:*

What is the primary caregiver's occupation:*

Please list the name and age of all household members.*

Do you currently own or rent the property you are residing at?*
Choose one: I own the property My parents own the property I am leasing the property

If applicable, please provide the owner/landlord's NAME, PHONE, & EMAIL.

Do you or any member of your household have any physical or medical conditions (including allergies) that should be taken into consideration relative to identifying an appropriate adoptive animal for your home? If yes, please explain.

Animal you are interested in meeting
Choose an animal: Korg Roxie SERI

Please list the name of any other animals you are interested in meeting.

Describe your ideal cat/dog (ie temperament, activity level, training level, etc,):*

Please describe your family life (activities, hobbies, schedules) and how a new dog/cat would fit in.*

Outside of household members, are there any children that visit regularly? If so, please list the age and frequency of any children who visit (Example, grandchildren, niece/nephew, a kid you may babysit, etc)*

Please list any pets that currently live with you (name, species/breed,gender, age).*

Veterinarian name, phone and address (either current or who you plan to use should you adopt)*

Are your household cats and dogs altered?*
Choose one: Yes No, due to a medically diagnosed condition No, I have chosen not to alter my dog/cat I do not own a cat or dog at this time

Per Illinois state law, all cats and dogs must be current on their rabies vaccination. Are your household animals current on their rabies vaccination?*
Choose one: I don't currently own a cat or dog Yes No, but I have an appointment scheduled within the next 3 days No, due to a medical condition No

Have you owned any pets in the last 5 years who do not currently reside with you? If yes, please explain why they are no longer living with you. *

Please list any other animals not residing with you that the adoptive animal would come in contact with.

Our animals are adopted out as an indoor family pet. If adopting a dog, do you agree to supervise the dog outdoors at all times? If adopting a cat do you agree the cat will be an indoor only cat?*
Choose one: Yes No

Do you have a fenced yard?*
Choose one: n/a - I'm adopting a cat My yard is fully enclosed with a fence (dogs can see/make contact with neighbor yards/animals) My yard is fully enclosed with a privacy fence (dogs cannot make contact with neighbors/animals) My yard is NOT fully fenced I do not have a yard - I will walk the dog on leash I have a fenced community area (ie: condo association dog run/park)

Please select how you will contain your dog outside.
Choose one: Fully fenced yard with no holes or gaps Tie Out Walk on a leash Electric fence

How many hours per day will your pet be left alone (on average)?*
Choose one: 0-2 3-5 6-9 10+

Please describe any special accommodations you will make for an adopted puppy or dog while you are at work/away from home. IE dog walker, friend to help during housebreaking stages, doggy daycare, family member, etc. If you do not need to, or do not plan to make any please note that below.

Where will the pet be kept during the day?*

How often do you plan on walking the dog?*
Choose one: n/a I'm adopting a cat Multiple times a day Once a day A couple times a week Rarely

What experience do you have with dogs/cats (please apply for the species you are applying for)? Ex: you've owned dogs/cats your whole life, you dog sit, family pets growing up, no experience*

Who will take care of your pet during vacations or overnight trips? *

If you are no longer able to physically care for the animal for its entire lifetime, what is your plan?*
Choose one: I would relinquish back to the rescue A family member has agreed to take over care I have not thought about it yet (but probably should)

How did you learn about the animal you are applying for?
Choose one: HWMAR Facebook Page Petfinder Friend/Family Referral HWMAR Volunteer Other

Please list a personal reference other than an immediate family member. Include Name, Phone number, Email and Relationship to you.*