Adoption Questionnaire
HOMEWARD BOUND PET RESCUE, INC.

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* = Required information

Adopting a pet is a lifelong commitment that should be taken seriously. We strive to match owner lifestyles with pet personality, special needs and breed type so that your pet will benefit from a healthy, fulfilling relationship. Please take a few minutes to fill out this questionnaire and return it to a Homeward Bound representative. * Applicant must be 21 years or older.

Applicant:
First Name: Last Name: Age: Occupation:
Co-applicant (Spouse or Significant Other):
First Name: Last Name: Age: Occupation:
Street address:
City: County: State: ZIP:
Home Phone: Work Phone:
E-mail (required field):


What is the name of the cat/dog and breed you are interested in?

List any general questions you would like to ask about this particular cat/dog:


Are you willing to allow a representative from Homeward Bound to visit your home by appointment? Yes No
Please check any of the following reasons for adopting this cat/dog:   family pet   child's pet   companion   companion for other pet   gift   other - please specify:
Please indicate where you live: apartment house condo/townhouse trailer/mobilehome
Do you... rent home own home
If you rent, do you have the landlord's permission to own a cat/dog? Yes No
      What is the apartment complex name?
      What is the landlord's phone number?
      How much is the pet deposit? $
How many times have you moved in the past 5 years? times
If you move, will your pet go with you? Yes No
Would you ever consider moving somewhere that doesn't allow your pets? Yes No
Do you foresee any major changes in your life in the next 15 years (average lifespan of a dog) such as marriage, childbirth, health problems due to age, going away to college? Yes No
If yes, please explain:
Do you or anyone in your household currently have any serious health problems? Yes No
If so, please describe:
Can you provide a permanent home for this cat/dog for 10-15 years? Yes No
What procedures will you use for litter box training? keep cat/kitten in one room with litter box have several litter boxes in house outside only; Other, please describe
Number of adults in household?
Relationship(s):   spouse   roommate(s)   life partner   other - please specify:
Does anyone in the household smoke? Yes No
Will this cat/dog be a surprise for any family members? Yes No
If yes, who?

Do any family members have allergies? Yes No
Do any children live in the house? Yes No
If so, what are their gender/ages?

Number, type and age of pets currently in household?
Do any of your current or did any of your past pets live primarily outdoors? Yes No
If yes, please describe pet:

Were all previous pets spayed/neutered? Yes No
Are all current pets spayed/neutered? Yes No

What is your veterinarian's name and phone number?
What do you expect annual pet care (vet care, medication, vaccines, etc.) to cost yearly?   $
How many cats/dogs have you owned in the past?
If any, please describe what happened to each of them (put to sleep, run over, died of old age, sold, given away, ran away, etc.)
Who will be responsible for the daily care and training of your new cat/dog?
How will you handle scratching or destructive behavior? loud noise declawing noise can; water gun; outside only; Other, please describe
How do you plan to prevent fleas and ticks?
Are you aware of Frontline or Advantage?
Yes No
How many hours will the cat/dog be home alone on a typical day?

Where does your current cat/dog stay when home alone during the day? outside garage inside in basement inside free run of house inside in one room of house ; other, please describe:
Where will your new cat/dog stay when home alone during the day? outside inside in basement in the garage inside free run of house inside in one room of house ; other, please describe:
Do you have a fenced yard? Yes No
How high is it?
What type of fence is it (privacy, chain link, pickett)?

Where do current pets sleep at night? inside in basement in the garage inside free run of house inside in one room of house in my bed ; other, please describe:
Where will the new cat/dog sleep at night? inside in basement in the garage inside free run of house inside in one room of house in my bed ; other, please describe:
What percentage of time will the cat/dog spend inside the house? %
Will your new pet be allowed on the furniture? Yes No
Have you ever had a serious behavior problem with a previous cat/dog? Yes No
If so, please describe:

Do you have a cat/dog door? Yes No
If not, and if it would work better, would you consider installing a cat/dog door? Yes No
Have you always kept an ID tag (other than a rabies tag) bearing your phone number on your pets? Yes No
Are you willing to keep a collar and ID tag on all of your pets including a new cat/dog at all times? Yes No
Under what circumstances do you think it is OK to leave a cat/dog outside alone and unsupervised in an unfenced area?   in a quiet subdivision   on a lot of acreage   in a rural area   none
What circumstances, in your mind, justify giving a cat/dog up?   moving   new baby   not getting along with other pets   divorce   behavioral problems   children lost interest   too time consuming   shedding   allergies   housebreaking problems   medical problems   aggressive behavior   other - please explain:
Have you ever given a cat/dog up or had a cat/dog for a brief period of time and it didn't work out? Yes No
If so, please explain the circumstances and what happened to it:

Have you ever looked at or applied for a pet with another rescue group? Yes No
If so, how long ago? Did you adopt? Please explain:
If you are unable to keep your cat/dog for any reason at any time will you return the dog to us? Yes No
If you date or marry someone who does not like or want your pets, what would you do?
If your pet later develops a medical problem that becomes expensive, what would you do?   Find another home for him   Pay whatever it takes   Have him put to sleep   Give him to a rescue group or shelter   other - please explain:
If your pet develops a frequent urination problem at the age of 12 and can't hold it when left alone, what would you do?   Have him put to sleep since he is older   Confine to one room where flooring is not carpeted  
Give him to a rescue group or shelter   Put in a cat door   other - please explain:
If you are considering a long-haired breed, how often would the cat/dog be groomed?

What type of food will you feed?   something from the grocery store   premium food from a pet supply store  
Brand name:
Has a cat/kitten/dog/puppy died on your premises in the last 6 months of feline leukemia, respiratory infection, PARVO or unknown causes? Yes No
Please list the names, addresses and phone numbers of 2 personal references:
How did you hear about Homeward Bound?   Homeward Bound website   Petfinder website   PetSmart   newspaper   word of mouth   radio   at an adoption day   other - please specify:
Typing your name below will serve as legal signature.
By signing below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for disallowing the adoption of rescue dog and possible removal of said dog from my home. Applicant must be 21 years of age or older. Homeward Bound reserves the right to refuse any applicant.


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