Avian Adoption Application Bird Name____________
Humane Society of Jefferson County, Inc.
We request the following information in an attempt to assist you with the selection of your companion animal. The animal’s welfare is our foremost consideration. This process is designed to help us determine if the placement is in the animal’s best interest and to assist you in finding an animal best suited to your lifestyle. H.S.J.C. reserves the right to refuse an adoption to anyone for any reason. No animal will be adopted to prospective owners who mislead or fail to provide accurate information on this application.
Please read the following information carefully.
Phone:_____________________ Alternate number:__________________________
Birth date: _________________Drivers License #__________________State________
City ________________________ State: ______Zip:__________County:___________
Email address: ___________________________________
How long have you lived at this address? ___________
What is the name of the bird you are interested in? ________________
Pre-approve this application (pet selection not yet made) Yes / No
Type of Residence
Circle one: House Apartment Duplex Mobile Home Farm
Live with friend/relative Condo Other____________________
If you rent or lease, please provide the following landlord information
Daytime phone: _____________________ Evening phone: _____________________
Are you planning to move in the next 6 months? Yes / No
Clinic name: ____________________________________
If you do not currently have a veterinarian, you will be asked to obtain one before the adoption is finalized.
Please list current pets and pets that you've owned in the past 5 years:
Species Name Age Neutered? Still own?
Are the animals listed under your name? Yes / No
If not yours, whose name are they under? ____________________________________
Are the pets you now own current on vaccinations? Yes / No
If you no longer own the pet, what happened to it?
Have you ever adopted from a shelter before? Yes / No When? _______________
What kind of pet?________________________________________________________
Have you ever surrendered an animal to a shelter? Yes / No When? _____________
What is your past experience with birds? Please circle.
First time owner Current bird owner Had a bird in the past
How will you correct behavior problems in your bird if they occur?
How much do you plan to spend per year to care for your bird? ____________________
How many hours a day will your bird be without human companionship? _____________
Are you a frequent traveler? Yes / No
Who will care for your bird while you are away?_________________________________
Where will you keep the bird during the day?___________________________________
Where will you keep the bird at night?________________________________________
Does anyone in the home smoke? Yes / No
Are you aware of an avian veterinarian in your area? Yes / No
What do you know about the type of bird you are adopting?
Would you like more information about birds? Yes / No
Are you willing and able to assume the financial responsibilities of pet ownership?
Yes / No
Are you prepared to commit to caring for your bird for the next 8 to 35+ years depending on the species?
Yes / No
If you must move from your current place of residence, what will you do with your bird?
Will you allow your bird adequate time to adjust to a new home? Yes / No
How long? ____________________________________________________________
Are you aware that birds require routine visits to the veterinarian? Yes / No
Please tell us a little about your household
What is the activity level of your household? Please circle.
Quiet Active Moderate activity
# of Children and Ages ___________________ Adults______________________
Who will be the primary caretaker?__________________________________________
This bird is being adopted as: Please circle all that apply.
Gift Companion For a child Companion for another pet
Does anyone residing in the house have any known pet allergies? Yes / No
Circle items you would like more information about.
Bird/Cat introductions Bird/Bird introductions Birds and Children
Care/Feeding Vaccinations Training methods
How did you learn about our organization? Please circle.
Pets of the Week Friend/Relative Phone Book Veterinarian
Radio Special Event Other ______________________
By submitting this document, you are stating that all the information given herein is accurate and complete and that you are hereby giving your consent for The Humane Society of Jefferson County to verify any and all information contained herein. The completion of this form does not entitle you to any guarantees or rights. HSJC will not be held liable in any way, for any animal, or its actions, once the animal has been placed.
Signature: _________________________________ Date:_________________
Received: Staff initials___________________ Date/Time:__________________
Office Use Only
Veterinary check _________________ Landlord approval __________________
Home ownership verified____________________ Pets licensed________________
Include all correspondence concerning application. Please date and initial.