Adopter’s Name *
Home Phone
Cell Phone
Work Phone
Vet's Phone
Past Veterinary Hospital
Past Vet's Phone
Is there a name besides yours that vet records would be listed under?
Have you owned pets in the past 7 years (do not include reptiles or birds)? * Yes No
Pet #1 Name
Pet #1 Breed
Pet #1 Age
Pet #1 Sex Male Female
Pet #1 Spayed/Neutered Yes No
Pet #1 still owned? Yes No
Pet #1 if no, why?
Add a second pet? Yes No
Pet #2 Name
Pet #2 Breed
Pet #2 Age
Pet #2 Sex Male Female
Pet #2 Spayed/Neutered Yes No
Pet #2 Still owned? Yes No
Pet #2 If no, why?
Add a third pet? Yes No
Pet #3 Name
Pet #3 Breed
Pet #3 Age
Pet #3 Sex Male Female
Pet #3 Spayed/Neutered? Yes No
Pet #3 still owned? Yes No
Pet #3 if no, why?
Add a fourth pet? Yes No
Pet #4 Name *
Pet #4 Breed *
Pet #4 Age *
Pet #4 Sex * Male Female
Pet #4 Spayed/Neutered? * Yes No
Pet #4 still owned? * Yes No
Pet #4, if no, why? *
Add a fifth pet? Yes No
Pet #5 Name *
Pet #5 Breed *
Pet #5 Age *
Pet #5 Sex * Male Female
Pet #5 Spayed/Neutered? * Yes No
Pet #5 still owned? * Yes No
Pet #5, if no, why? *
Add a sixth pet? Yes No
Pet #6 Name *
Pet #6 Age *
Pet #6 Breed *
Pet #6 Sex * Male Female
Pet #6 Spayed/Neutered? * Yes No
Pet #6 still owned? * Yes No
Pet #6, if no, why? *
Add a seventh pet? Yes No
Pet #7 Name *
Pet #7 Breed *
Pet #7 Age *
Pet #7 Sex * Male Female
Pet # 7 Spayed/Neutered? * Yes No
Pet #7 still owned? * Yes No
Pet #7, if no, why? *
Add an eighth pet? Yes No
Pet #8 Name *
Pet #8 Breed *
Pet #8 Age *
Pet #8 Sex * Male Female
Pet #8 Spayed/Neutered? * Yes No
Pet #8 still owned? * Yes No
Pet #8 if no, why? *
Add a ninth pet? Yes No
Pet #9 Name *
Pet #9 Breed *
Pet #9 Age *
Pet #9 Sex * Male Female
Pet #9 Spayed/Neutered? * Yes No
Pet #9 still owned? * Yes No
Pet #9, if no, why? *
Add a tenth pet? Yes No
Pet #10 Name *
Pet #10 Breed *
Pet #10 Age *
Pet #10 Sex * Male Female
Pet #10 Spayed/Neutered? * Yes No
Pet #10 still owned? * Yes No
Pet #10, if no, why? *
What type of residence do you utilize? * House Duplex Apartment Condo Mobile Home Military Housing
Do rent or own your home? * Rent Own
Landlord's Phone Number:
Who will become this pet’s guardian if you lose your home, move or are no longer able to care for this pet?
Are there other people living in your household? * Yes No
Resident #1 *
Age #1 *
Add a second person? Yes No
Resident #2 *
Age #2 *
Add a third person? Yes No
Resident #3 *
Age #3 *
Add a fourth person? Yes No
Resident #4 *
Age #4 *
Add a fifth person? Yes No
Resident #5 *
Age #5 *
Add a sixth person? Yes No
Resident #6 *
Age #6 *
Add a seventh person? Yes No
Resident #7 *
Age #7 *
Add an eighth person? Yes No
Resident #8 *
Age #8 *
Add a ninth person? Yes No
Resident #9 *
Age #9 *
Add a tenth person? Yes No
Resident #10 *
Age #10 *
Have you adopted from LRHS in the past? If yes, when and whom?
Have you ever had to surrender an animal? If so, please explain:
Are you willing to dedicate 2-4 months to helping this pet adjust to your home? * Yes No
Are your current pets to date on rabies & distemper vaccinations? * Yes No I don't currently have pets
Are your current pets spayed/neutered? * Yes No I don't currently have pets
If no, why? *
Where will your new pet spend most of its time? * Outside Inside Basement Attic Kennel Garage Other
Date *
