Apply to Adopt a Dog Form

Apply to Adopt a Released Dog

Contact Information - ** indicates required fields

Name of Applicant^**

Street Address or P.O. Box^**

Apartment/Unit #

City^**

State^**

Zip Code^**

Home Telephone Number^**

Cell Telephone Number^**

E-mail Address^**

Date of Birth^**

Occupation^**

Home Information - ** indicates required fields

Is your Residence a^**

Is your Residence in the

Do you have a fenced-in area?^**

If Yes, how large?

On an average day, how many hours would the dog be left alone^**

How many hours would the dog be left alone at any one time?^**

Would you be willing and able to attend dog classes?^**

List the name, age, and relationship to you of everyone living in your home.

Do you have other animals in your home?^**

If YES, list the type, sex, whether neutered, and age of each animal.

Availability & Experience - ** indicates required fields

Why do you want a released dog?^**

Do you have any previous experience with dogs?^**

If YES, please explain.

References - ** indicates required fields

Please list at least one person who knows you well who we can contact for a reference.

First Reference

Full Name of Reference^**

Street Address or P.O. Box^**

Apartment/Unit #

City^**

State^**

Zip Code^**

Telephone Number

E-mail Address^**

What is their relationship to you?

Second Reference

Full Name of Reference^**

Street Address or P.O. Box^**

Apartment/Unit #

City^**

State^**

Zip Code^**

Telephone Number

E-mail Address^**

What is their relationship to you?

Please review the above information prior to submitting.
If correct, submit the information using the button below.

Apply to Adopt a Dog Form

KHS.org

Keystone Human Services adopt a dog form

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Apply to Adopt a Released Dog