WAHSDog Adoption Application
*Date: _____________ **Adopters must be 21 or older
Name:_________________________________
Address:_______________________________ City: _______________ State:_______ Zip:_______
Phone: (H)____________________ Phone (W)____________________
Email:_________________
• Photocopy of Driver’s License is required. Submitted: Yes No
By signing you agree to allow the WAHS to run a background check:
**Signature:______________________________
Type of residence: House Duplex Apartment Condo Mobilehome
Do you: ___ Rent (fill out a Landlord Verification form) ___ Own ___ Live with the home owner
Name of Landlord: ___________________________________ Phone: ________________________
Your employer:______________________________ How long? _____________ Retired
May we call them? Yes No Phone: ___________________________
Does your job require extensive travel? Yes No
Number of adults in the household: ______ Children:_____ Children’s age(s):_________________
Do any members of your household have allergies or asthma? Yes No
REFERENCES:
Please list two references who do not reside with you. No relatives.
Name: ____________________________ Relationship: ____________ Phone: __________________
Name: ____________________________ Relationship: ____________ Phone: __________________
PET INFORMATION:
What qualities are you looking for in a pet:
_________________________________________________________________________________
What pets have you owned in the past 2 years? Do any pets reside with you now?
Pet’s Name Breed/Type Age Sex Fixed (Y/N) Still Own (Y/N)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
* If not spayed or neutered, please explain: ______________________________________________
Dog Adopt [Link]
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If you no longer own these pets, please explain: ___________________________________________
Have you applied to or adopted from the WAHS or any other shelter before? Yes No
If yes, when/what shelter was that? ____________________________________________________
Have you ever given away an animal, or surrendered an animal to a shelter? Yes No
What shelter and when? ___________________________________________________________
If yes, describe the circumstances: ___________________________________________________
WAHS will contact your vet regarding your recently owned pets. Please initial that you give your vet
permission to disclose that information to us. **Initial:______
If you could please contact your vet and let them know we will be calling, it will make the process go
much quicker.
Name of the veterinary clinic that has cared for your pets:
Pet Medical Center • 454-2600 Companion Animal Care Center • 452-9189
Winona Veterinary Hospital • 452-4811 Lewiston Veterinary Hospital • 523-2136
Other Clinic: _______________________ City: ___________________Phone: _______________
Why would you like to adopt this animal?_______________________________________________
Companion Guard Dog Family Pet Hunting Dog
How many hours per day will this dog be alone (no one home)? _________________
Where will this dog be primarily kept? Indoors Outdoors
If outdoors, please describe the shelter provided: ____________________________________
____________________________________________________________________________
____________________________________________________________________________
How will you exercise your dog? Check all that apply:
Fenced Yard Loose outside On leash Hiking/Jogging
Have you ever attended obedience school with a dog? Yes No
Are you familiar with Crate Training? Yes No
How have you used a crate?
____________________________________________________________________________
____________________________________________________________________________
Dog Adopt [Link]
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Are you willing to learn about crate training as an option for problem solving? Yes No
If the dog you adopt is not house-trained, or needs basic skills to be a good companion in your home,
what steps will you take? ______________________________________________________
___________________________________________________________________________
Have you ever dealt with behavior problems such as excessive digging, barking, jumping up or
chewing? Yes No
How will your dog be confined to your property if outside? (Check all that apply)
Dog House Barn Fenced Yard
Loose Outside Electric Fence Outside Kennel/Pen
Tied Outside, how? Other ______________
When you are NOT home where will you keep this dog? Check all that apply:
Dog House In the Home Tied Outside
Fenced Yard Crate In Home Loose Outside
Garage Basement Outside Kennel/Pen
Barn Dog Daycare Other __________________________
I understand that the life span of a dog can range from 12-17 years. **Initials:________
I understand that by agreeing to adopt this dog, I am making the decision to care for him/her for his/her
lifetime. **Initials:______
If for any reason you can no longer keep the animal you adopt, and you cannot find a new home for it,
do you agree to contact WAHS before taking other measures? Do you: Agree Disagree
WAHS Information and Questions
- Dogs who are not spayed/neutered require a $100 deposit check per dog at the time of adoption.
This check will be returned after the procedure is performed (procedures performed at WAHS),
but if you choose to have the procedure done, at your expense, we will need proof that it has
been done before you receive your check back.
- WAHS does not allow dogs adopted from our shelter to be “trained” with shock collars. They have
been proven to cause negative associations with certain people, objects, etc. and can actually
cause problems to become worse.
Do you agree to honor our policy on shock collars? Yes No
I certify that the above information is accurate. I understand that to misrepresent any information
grants the Winona Area Humane Society the authority to refuse adoption or reclaim an adopted pet.
Print Name: _________________________________
Dog Adopt [Link]
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Signature: __________________________________
Dog Adopt [Link]
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