Hickory Hill Canine Rescue Adoption Application

We are committed to finding permanent, responsible, and loving homes for our rescue pets. Hickory Hill Canine Rescue reserves the right to adopt to homes it deems suitable for the pet based on the applicant’s history and factors including: temperament, family, lifestyle, yard and housing needs. Animals will not be adopted to anyone running a daycare program for children out of their home. All animals of age will be altered by Hickory Hill Canine Rescue before going to their new home. All animals must be altered by the age of 6 months by Virginia State Law. You must be at least 18 years old to adopt an animal. Please be aware that the adoption process may take a while and the adoption may not occur today. Home visits may be requested and follow-up visits may occur.

Date of Application:

If interested in a specific animal please list:   Name:    ID Number
Name:    
Street:      Apartment:
City:        State:     Zip:
Home Phone:     Work Phone:     Extension:
 Best Time to Call:
E-mail Address (if you have one):   
1. Home Life Information:

If you are single:
Do you live alone?   Yes    No       Live with family? Yes   No
Do you work?         Yes    No       If so, what hours?
If you are married:
Does spouse work? Yes    No       If so, spouses work hours?
How many children do you have at home?    (Please include visiting grandchildren.)
Age of children:
Who will be responsible for the pet?   Husband    Wife    Children
2. Residential Information:
Do you:    Own    Rent
Type of dwelling:  House    Mobile Home   Apartment    (Floor #)
Do you have a fenced yard?   Yes    No
If so, please describe fenced in area such as height, type:
If renting, does the lease allow pets?   Yes    No    Don't know
Name of leasing company:       Phone #
Are you planning to move anytime soon?   Yes    No
Will your moving affect your ability to keep the animal being applied for?   Yes    No
Where will your pet be kept?     Daytime       Evenings
Does anyone in your residence have allergies to pets?     Yes    No
If someone in the family is allergic what steps will be taken to try and keep the animal in your home?
3. Pets:
Do you have other pets now?     Yes    No
Type: Breeds:
Where do you keep your pets?      Indoor    Outdoor    Indoor/Outdoor
How long have you had your pets?
Are your pets(s) neutered or spayed?       Yes    No
Are your pets(s) current on ALL shots?    Yes    No
Are your pet(s) currently on hartworm testing and preventative?      Yes    No
Do you have a regular veterinarian:     Yes    No
Name:   
Address:
Phone #:
May we contact the veterinarian to verify the above information?      Yes    No
Have you had pets in the past?      Yes    No
What happened to the pets:
Have you ever adopted from any other rescue organization?     Yes    No
If yes, please list which one.
Where is the pet now?        
Have you ever turned in any animals to an animal shelter before?     Yes    No
If so, what was the reason? 
Have you ever been reported to an animal shelter before?     Yes    No
If so, what was the reason? 
Have you or anyone in your family or household ever been charged with animal cruelty, failure to provide adequate veterinary care, or neglect?     Yes        No
4. What are you looking for in a pet?     Puppy       Dog       Kitten       Cat
Who is the pet for?     Self       Children
What size pet are you looking for?  Small     Medium     Large
What behavior problems would you find unacceptable and how would you deal with them should this pet exhibit these behaviors?
5. Miscellaneous information:
Please list two personal references below along with their phone number:
1.
2.
Your occupation:      Your employer:
How did you hear about Hickory Hill Canine Rescue and this animal?
Are you aware that the first year routine vet expenses range from $150 - $200?   Yes     No
Hickory Hill Canine Rescue expects that you are going to make a lifelong commitment to this pet. Do you anticipate any major lifestyle changes (moving, marriages, new baby?)    Yes No
Please explain:
Do you know the local ordinances pertaining to licensing, rabies, vaccinations, and leash laws?   Yes      No
Do you know about: Viruses (Parvo/Distemper)? Yes    No
Feline Aids?         Yes    No Parasite Control?                    Yes    No
Feline Leukemia? Yes    No Bordatella?                               Yes    No
Cystitis/Feline Urinary Stones? Yes    No Hartworm Disease?                 Yes    No
Please print this form before clicking the "SUBMIT INFORMATION" button below.

      

Hickory Hill Canine Rescue highly recommends flea control products available at your veterinarian. Dogs need to be on heartworm preventative all year long. Puppies and kittens need to be vaccinated every three weeks through 4 months of age in order to give them the protection they need to fight viruses. Adult dogs and cats should receive at least two vaccines--three weeks apart. Rabies vaccine is given after 4 months of age. Cats and dogs should be inoculated for rabies yearly. The first rabies vaccination is valid for one year. After that the rabies vaccine is good for three years. Please do not take your pet to public places until the proper inoculations have been given. By signing an adoption contract you promise Hickory Hill Canine Rescue that you will provide proper medical care for this pet. This includes yearly vaccinations, yearly heartworm testing, and heartworm preventative.

HICKORY HILL CANINE RESCUE RESERVES THE RIGHT TO CONFISCATE ANY PET IT ADOPTS TO AN APPLICANT GIVING FALSE INFORMATION ON THIS APPLICATION. I AUTHORIZE VERIFICATION OF ALL STATEMENTS IN THIS APPLICATION WITH VETERINARIAN/REFERENCES/ LANDLORD. HICKORY HILL CANINE RESCUE RESERVES THE RIGHT TO DENY ADOPTION TO ANYONE WHO, IN ITS OPINION, WILL NOT PROVIDE A SUITABLE AND RESPONSIBLE HOME FOR THIS PET. Hickory Hill Canine Rescue adoptions are based on compatibility, history, temperament, and lifestyle.

Name of Hickory Hill Canine Rescue Representative: ______________________________
Signature of Hickory Hill Canine Rescue Representative: ____________________________
Name of Adopter:________________________________________________________
Signature of Prospective Adopter: ____________________________________________
Date Signed: _______________

Name of Pet adoptee is interested in: ___________________
Canine____M___F___    Feline____M___F___


Internal Use Only: CIRCLE ONE: APPROVED DENIED
If Denied please state why:
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