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 Adoption Information Are you applying for yourself or someone else? - Select -MyselfSomeone Else Other Person Contact Info First Name Last Name Email Cell Phone Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Are You Applying for a Dog or Cat? Name of Adoptable Pet Housing Information Housing - Select -I Own I Rent Landlord Name Landlord Phone Number How long have you been at your current address? Do you have a fenced yard? - Select -YesNo How tall is your fence? Lifestyle Information List the Ages of All Individuals in Your Household Pet-Related Allergies? - Select -YesNo Please Explain Are you currently employed? - Select -YesNo What is your occupation and employer? How many hours per day will the pet usually be left alone? Please explain the usual activity level in your home. Will the pet primarily live inside or outside of your home? Current / Past 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 If needed, are you able to provide emergency vet care for the pet? If needed, are you able to provide emergency vet care for the pet? - Select -YesNoOther… Enter other… Have you ever had to surrender a pet you've owned? - Select -YesNo Please explain Have you ever lost a dog to an accident or escape? - Select -YesNo Please Explain Behavioral Information Are you willing to seek help to correct pet behavioral problems (such as calling the shelter for advise)? - Select -YesNo If something happened to you or you have to move where pets are not allowed, what would be your plans for the pet? 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
