Kent County Animal Shelter- Dog Adoption Survey
Spouse’s Name: Date:
City: State: Zip:
Phone 1: Phone 2:
Are you over 62 years of age? Yes No
Name:
Address:
Email:
Are you over 18 years of age? Yes No
General Information:
1. Please list household members:
Name
Age
Relationship
2. Do you run a day care or babysitting service in your household? Yes No
3. Do you OWN your home or RENT your home?____________________________________
4. If you rent, or live in a home owned by a relative, what is your landlord’s/relative’s name and phone number?
_______________________________________________
5. List all dogs, cats and ferrets CURRENTLY living at your home:
Name
Breed
Age
Sex (M/F)
Neutered?
How long owned?
6. List all dogs & cats who have lived with you in the past 5 years but who are NOT CURRENTLY with you:
Name
Breed
Age
Spay/Neutered?
Indoor or Out?
Where is the animal now?
7. How often do children or teens visit?
o Daily
o Numerous times/week
o 1-4 times monthly
o Infrequently
8. Would you say your current lifestyle
is
o Very Hectic
o Moderately busy/ controllable
o Calm/ Quiet
9. Are there any major family changes
in your near future?
o Birth of a child
o Household move
o Schedule Change
o Marital Change
o Other
10. Is anyone in your family allergic to
animals?
o No
o Yes
If yes, please specify
11. What will your pet’s indoor areas
include?
o Full access to rooms
o Limited access to rooms
o Allowed on furniture
o Allowed on some furniture
12. Where will your pet sleep?
o Crate
o Their own bed
o Family member’s bed
o Outside
o Other
13. Where will your pet be kept when
you are not home?
o Crate
o Outside
o Free access to house
o Speci fic room
14. How much time do you plan on
interacting with your dog daily?
(training, playing, grooming, exercise,
etc)
o < 1 Hour
o 1-2 Hours
o >3 Hours
15. Prioritize 3 activities you would like to
do with your pet (fetch, jogging, etc)
1)
2)
3)
16. How often will you walk your pet off
your property for mental stimulation?
o Twice daily
o Once daily
o Once weekly
o Less than once a week
17. Who will be in charge of feeding?
o Family members take turns
o Mom/Dad
o Individual
18. Who will be in charge of cleaning up?
o Family members take turns
o Mom/Dad
o Individual
19. Approximately how long will your dog
be left ALONE on a typical day?
o 1-4 hours
o 4--8 hours
o 8-10 hours
o More than 10 hours
20. Do you plan on crate training your
pet?
o Yes
o No
o Unsure, need more information
21. Who will be responsible for
veterinary care?
o Family members take turns
o Mom/Dad
o Individual
22. Would you prefer to have your pet
trained…
o Without assistance
o With the help of a private trainer
o Group training class
o Leave pet at a training facility
o Unsure, need more information
23. What other animals (not your own)
will your pet interact with?
o Dogs
o Cats
o Other
o Often
o Rarely
o Never
24. If you have other pets, how will you
handle introducing a new dog?
o Keep separate at first
o Slowly over several days
o Put new dog on leash
o Just put them together
25. How much will you budget monthly
for your dog’s food?
o $20-$50
o $50-$100
o More than $100
26. What type of food will you feed your
dog?
o Dry
o Canned
o Table Scraps
o Prescription if needed
27. How much will you budget to spend
annually on your dog’s medical
care?
o Less than $200
o $200-$400
o $400-$600
o More than $600
o Whatever is necessary
28. Which veterinary hospital or clinic
do you use?
29. Primary purpose for obtaining your
pet:
o Companion
o Family pet
o Child’s pet
o Hunting
o Protection
o FB arm/outside pet
o Other
30. Has someone in your household
owned a puppy less than 6 months of
age?
o Yes
o No
o How long ago?
31. House training problems
o Could live with the problem
o Would do whatever it takes to
correct the problem
o Problem would prompt me to
part with the pet
32. Excitability
o Could live with problem
o Would do whatever it takes to
correct the behavior
o Problem would prompt me to
part with the pet
33. Excessive Vocalization
o Could live with problem
o Would do whatever it takes to
correct the behavior
o Problem would prompt me to
part with the pet
34. Jumps on people.
o Could live with problem
o Would do whatever it takes to
correct the behavior
o Problem would prompt me to
part with the pet
35. Chewing/Digs/Destructive
o Could live with problem
o Would do whatever it takes to
correct the behavior
o Problem would prompt me to
part with the pet
36. How important is it to you that your
pet want to sit in your lap, follow
you around, etc?
o Very important
o Important
o Not Important
o I would rather have an
independent dog
37. How do you plan to groom your pet?
o At home
o Professionally if necessary
o As infrequently as possible
Certification, Authorizations, Releases and Understandings
1. I certify that all statements on this adoption application are made truthfully and without evasion, and further understand and agree
that such statements may be investigated and if found to be false will be sufficient reason for not being allowed to adopt from the
Kent County Animal Shelter (KCAS).
2. I authorize the KCAS to contact my veterinarians(s) and anyone else KCAS deems necessary to confirm how I have cared for my
companion animals and/or how I am likely to care for any companion animal(s) I adopt from KCAS.
3. I authorize my veterinarian(s) to release to KCAS all veterinary records of the animals I own or have owned.
4. I understand that, with proper care, dogs can live 15 years or more and I am prepared to commit myself to the long-term care and
protection of any animal I adopt from the KCAS.
5. I understand that animal(s) I adopt from KCAS may require veterinary medical or health treatment beyond that provided by
KCAS prior to my taking the animal(s) home. Such additional veterinary medical treatment could be costly. I acknowledge that
KCAS is not responsible for providing any additional veterinary treatment or the incurring cost of any additional veterinary
treatment provided by veterinarians I select to provide such treatment.
6. I will not sell or give away animal(s) I adopt from KCAS. As long as I live in the service are of KCAS, I agree to return the
animal(s) to KCAS in the event I cannot keep or choose not to keep the anima(s). If I move from the are, I agree to take the
animal(s) to the local humane society or comparable local animal welfare organization.
Date:___________________________________ Applicant Signature:____________________________________________
if applying electronically, please type your name on the line