21001 MO-78 Highway, Independence, MO 64057 • PH: 816-325-7207 • Email: PetAdoptions@indepmo.org
Adoption Survey
Name and Phone Number for an Emergency Contact Person for the Microchip Registration:
What traits are you NOT willing to work with? Check all that apply.
Dislikes Cats ꙱ Dislikes Dogs ꙱ Dislikes Kids ꙱ Escape Artist ꙱ Scratches Furniture
Separation Anxiety ꙱ Jumping Up ꙱ Plays Rough ꙱ Biting ꙱ Excessive Vocalization
꙱ Other ______________________________________
During the Day
At Night
On average, how many hours will your pet spend alone daily?
To expedite the adoption process, you may choose to provide the following information:
Driver's License #:
Date of Birth
Where will your pet be kept...?
꙱ House training/litterbox issues
Medium: daily walks, moderate exercise.
Low: calm/mature/senior; yard time exercise.
Very active: kitten/young cat, lots of playtime!
Medium: enjoys playtime and long naps.
Low: a calm, mature cat; senior; couch potato.
High: needs lots of exercist, running, hiking,
Other dog(s):
Other cat(s):
Other pet(s):
What energy level are you
looking for in a new dog?
What energy level are you
looking for in a new cat?
Baby on the way:
Alt. Phone
Are you over 18 years of age? Yes ꙱ No
Name/type of pet you are inquiring about?
A shelter representative will contact you as soon as possible to provide information regarding the pet(s) you have
listed above. What are the best times of day to reach you by phone?
How would you describe your household? (check all that apply)
Kids-please list ages: