Please fill out the form below. Once complete, you will receive an automatic reply with next steps! Thank you for your interest in adopting from NHS! Today's Date Contact Information First Name Last Name Personal Email 21 Years or Older? - Select -YesNo Street Address Street Address cont'd City State Zip Code Home Phone Cell Phone Work Phone We noticed you are applying from out of state. This is not a problem at all, but we do want to make sure you are aware we are located in Covington, Louisiana before proceeding. Is this okay? - None -YesNo List the Ages of All Individuals in Your Household Pet-Related Allergies? - Select -YesNo Please Explain Housing Information Housing - Select -I Own I Rent Landlord Name Landlord Phone Number Adoption Information Are You Applying for a Dog or Cat? Name of Adoptable Pet Current Pet Information Do You Have Previous Pet Ownership Experience? - Select -YesNo Do You Currently Have Pets? - Select -YesNo How many pets currently live in the home? - None -1234 or more Pet Name 1 Pet Age 1 Pet Species 1 Pet Name 2 Pet Age 2 Pet Species 2 Pet Name 3 Pet Age 3 Pet Species 3 Please list the names, ages and species of the remaining pets in the home. Are Your Pets on Heartworm Preventative? - Select -YesNo What Vet Clinic Does Your Family Use? Vet Clinic's Phone Number Upload Current Medical Records for All Pets You can upload up to 5 items. Upload Upload requirementsMaximum 5 files.200 MB limit.Allowed types: gif, jpg, jpeg, png, txt, pdf, doc, docx. Are you willing and financially able to provide the routine veterinary care that this pet will need? - Select -Yes No Are you willing to seek help to correct pet behavioral problems (such as calling the shelter for advise)? - Select -YesNo How did you hear about our adoption program? Social Media TV Appearance Radio Interview Word of Mouth Google Newspaper Other None of the above Verification I hereby verify that I am 18 years of age, or older, and all information on this application is true to the best of my knowledge. Yes No Applicant's Signature Reset Print Name Date CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank
