Adoption Application This is required for ALL adoptions. Step 1 of 5 20% NameThis field is for validation purposes and should be left unchanged.Would you prefer to complete and send in a paper application? Yes Print an application Download and print a PDF adoption application, complete it, and bring it to the Pet Adoption Center. Adoption applications are also available at the Pet Adoption Center. Cat adoption form Dog adoption form Rabbit adoption form Other pet adoption formType of pet you're interested in adopting(Required) Dog Cat Rabbit Other Name of pet you're interested in adopting(Required)Name of adopter(Required) First Middle Last Age verification(Required) I certify that I am 21 years of age or older Adopter's email(Required) Adopter's emailCo-adopter(s)Name(s) of all other adults in the homeAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required)AdamsAlexanderBondBooneBrownBureauCalhounCarrollCassChampaignChristianClarkClayClintonColesCookCrawfordCumberlandDeKalbDeWittDouglasDuPageEdgarEdwardsEffinghamFayetteFordFranklinFultonGallatinGreeneGrundyHamiltonHancockHardinHendersonHenryIroquoisJacksonJasperJeffersonJerseyJo DaviessJohnsonKaneKankakeeKendallKnoxLakeLaSalleLawrenceLeeLivingstonLoganMaconMacoupinMadisonMarlonMarshallMasonMassacMcDonoughMcHenryMcLeanMenardMercerMonroeMontgomeryMorganMoultrieOglePeoriaPerryPiattPikePopePulaskiPutnamRandolphRichlandRock IslandSalineSangamonSchuylerScottShelbySt ClairStarkStephensonTazewellUnionVermilionWabashWarrenWashingtonWayneWhiteWhitesideWillWilliamsonWinnebagoWoodfordPrimary phone(Required)(555) 555-5555Alternate phone(555) 555-5555Please send me information (email or text) on shelter events Yes No Do you: Attend school? Work? EmployerSpouse or partner's employerDo you live in a:(Required) House Apartment Condo Dorm Mobile home Do you:(Required) Rent Own Live with parents Landlord's name(Required)Landlord's nameLandlord's phone(Required)(555) 555-5555Parents names(Required)Parents phone(Required)How long have you lived at your current address?If less than one year, list your previous address and how long therePlease provide the following information about your household:Number of adults(Required)Please enter a number greater than or equal to 0.Number of children(Required)Please enter a number greater than or equal to 0.Ages of childrenDo the children live in the home full time? Yes No How many pets do you have now?Dogs(Required)Please enter a number greater than or equal to 0.Cats(Required)Please enter a number greater than or equal to 0.How many pets have you had in the last five years?Please enter a number greater than or equal to 0.Please list any pets you now have or have had in the past. Include name, type or breed, age, sex, is the pet fixed, and why you no longer have the pet. If more space is needed provide details to the Adoption Counselor.Current or past pet 1Current or past pet 2Current or past pet 3Current or past pet 4Current or past pet 5Have you ever adopted a pet from HSCI? Yes No When did you adopt a pet from HSCI?Are your current pets up to date on vaccinations and other necessary vet care?Which veterinarian would have records, current and past?Vet's phone number(555) 555-5555Whose name are the vet records under?Which veterinarian do you plan to use? Who will be primarily responsible for the care (feeding, grooming, exercise and training) of your new pet?(Required)Do you plan on taking the dog to training classes?(Required) Yes No How much do you anticipate spending yearly on food, vet care and other expenses for your pet?(Required)Have you had a rabbit before? Yes No Where is the rabbit now?How much time will your pet be alone without human companionship?Hours a day(Required)Please enter a number greater than or equal to 0.Days a week(Required)Please enter a number greater than or equal to 0.Will your dog stay:(Required) Primarily inside Outside only Will your cat be allowed outdoors? Yes No Do you plan on declawing your cat?(Required) Yes No Which paws will you declaw?(Required) Front paws only All four paws Where will the dog be kept when home alone?(Required)Where will you exercise the dog?(Required)How often will you exercise the dog?(Required)Do you have a FULLY fenced yard?(Required) Yes No What type of fence? Wood Chain link Other Describe how you will housetrain a dog(Required)How will you discipline or correct your dog?(Required)How long do you expect it to take your new dog to adjust to its new home and learn proper behaviors?(Required)How will you teach your cat to stay off counters?(Required)How will you teach your cat not to scratch furniture?(Required)What will you do if your cat urinates outside the litter box?(Required)How long do you expect it to take your new cat to adjust to its new home and learn proper behaviors?(Required)Do you have the proper cage and supplies? Yes No Is your home and yard bunny-proofed? Yes No Do you have animals that could endanger the rabbit? (Rabbits can die when frightened by a predator.) Yes No If yes, what animal?Where will you keep the rabbit? Inside Outside Are you interested in adopting a: Dog Puppy No preference Are you interested in adopting a: Cat Kitten No preference Up to what age?Please enter a number greater than or equal to 0.Sex Male Female No preference Hair length?Hair length Short Medium Long No preference Weight or size as an adult?ColorAny other specifics you'd like to tell us about? By entering my name below (and spouse/partner if applicable), and clicking the 'Submit Application' button, I certify that the information given is true and correct and I recognize that any misrepresentation of facts will result in my losing the privilege of adopting a pet. I also give my veterinarian permission to release any vet care records and information about my current and past pets to the Humane Society of Central Illinois. I understand that this application is the property of the Humane Society of Central Illinois and that the Humane Society of Central Illinois has the right to deny my request to adopt. In the event of an adoption, In the event of an adoption, I authorize the Humane Society of Central Illinois to share my email and information with Hill's Science Diet and the pet’s microchip manufacturer. I authorize the Humane Society of Central Illinois to use my likeness in a photograph in any and all forms and media, including but not limited to publications, brochures, websites, exhibitions, digital media, social media such as Facebook, and any other printed or digital publications.Signature(Required)Date(Required) SignatureDate
