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Other Animal Adoption Application

Section I - Contact Information

Section II - Personal Information

Section III - Animal Care History

(Please fill out Section IV)

Section IV - Veterinary Information

Statement of Understanding:

I understand the responsibilities that I am assuming if I adopt this animal. I know that there may be
unforeseen circumstances and expenses, including annual vet visits, with the introduction of a new pet in my
household.
I hereby give the Humane Society of Greater Dayton my permission to contact my landlord, if applicable, and
my veterinarian to verify any of the information supplied in this application. I also agree to a “progress check” in
the future, where a Humane Society worker may visit my home to verify my new pet’s living conditions. I
agree that if I am unable to keep this pet for any reason, I will contact the Humane Society of Greater Dayton.
By signing below, I acknowledge that I understand everything I have read in this application and I
have answered all of the questions truthfully. I further understand that the Humane Society of Greater
Dayton is considered the guardian of the animal in question and has the right, in its sole discretion, not to
approve this application.