Dog Adoption Application Online

We realize that adopting a new furry friend can be very exciting and emotional, as it’s such an important and life-changing decision! Because of this, we are very thorough in our adoption process, making every effort we can to find the best possible match for a forever home for each of the animals here at the Humane Society of Harrisburg Area, Inc. Please understand that we do reserve the right to deny an adoption application based on our discretion to place our animals in the best possible home environment.

Again, please answer ALL questions. Incomplete applications will cause your application to be delayed or denied. Your Driver’s License or Photo Identification Card is required which reflects your current address.
Let's Get Started
Name of the Dog for which you are applying*
Is this your first experience owning a dog?*
- Yes
- No
Have you owned this breed before?*
- Yes
- No
Tell Us About Yourself
Name*
First Last
Birthdate*
Date Format: MM slash DD slash YYYY

Please note: in order to be considered an adopter, you must be at least 18 years of age
Your Age*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
Place of Employment. If unemployed, write "unemployed"*
Employer Phone. If unemployed, write "(111) 111-1111"*
If unemployed, or a student, please list your source(s) of income
List the names and ages of any persons living with you, and their relationship to you
Individual 1
First Last
Individual 1 Age
Individual 1 Relationship
Individual 2
First Last
Individual 2 Age
Individual 2 Relationship
Individual 3
First Last
Individual 3 Age
Individual 3 Relationship
Individual 4
First Last
Individual 4 Age
Individual 4 Relationship
Please list any additional family members below
Does anyone in your household have dog allergies?*
- Yes
- No
Are they on medication for it?*
- Yes
- No
- Not applicable
Have any members of your family ever been charged with and/or convicted of Animal Cruelty?*
- Yes
- No
Have you ever adopted an animal from a shelter below?*
- Yes
- No
If yes, what was the name of the shelter?
Have you ever taken an animal to a shelter before?*
- Yes
- No
If yes, why?

Tell Us About the Pets You've Had Before!
Dogs
Cats
Other
Animal #1 Name
Animal #1 Species
Animal #1 Breed
Animal #1 Age
Animal #1 - why do you no longer have this pet?
Animal #2 Name
Animal #2 Species
Animal #2 Breed
Animal #2 Age
Animal #2 - why do you no longer have this pet?
Animal #3 Name
Animal #3 Species
Animal #3 Breed
Animal #3 Age
Animal #3 - why do you no longer have this pet?
Please list any additional animals below

Personal References
Please do NOT list family members
Reference #1 Name*
First Last
Reference #1 Address*
Street Address City State ZIP Code
Reference # 1 Phone*
Reference #1 Relationship to You*
Reference #2 Name*
First Last
Reference #2 Address*
Street Address City State ZIP Code
Reference #2 Phone*
Reference #2 Relationship to You*
Your Veterinarian
To expedite the application process, please provide us with proof of your current pets' up-to-date vaccine records/documentation. If this is your first pet, please list the veterinarian you plan to see for the care of your dog.
Attach pets' vaccination records/documentation
Untitled*
- I have attached my pets' vaccination records above
- My vet or myself will fax vaccination records to you at 717-564-1867
- I do not have any pets at this time
Are your current pets up-to-date on vaccines?*
- Yes
- No
- Not applicable
Is your name listed as the Primary Owner of the listed pet(s) with the Vet or Clinic's Office?*
- Yes
- No
- Not applicable
If you answered No, who's name is listed as the Primary Owner?
Veterinarian's Name*
Address*
Street Address City State ZIP Code
Phone*

Acknowledgement & Release
Please place a check mark next to each statement confirming your agreement and understanding*
- I understand that the Humane Society of Harrisburg Area, Inc. is not able to give any guarantees on the health, training, or temperament of this animal and that the adoption fee(s) is not refundable under any circumstances.
- I understand and accept that authorized Humane Society of Harrisburg Area, Inc. agents sometimes will do follow-up visits to an adopter’s home to check on the care the animal is receiving and can remove the animal if unsatisfied with the viewed conditions.
- Unanswered questions, incomplete answers, and/or false information may result in this animal’s Adoption Application being denied. The Humane Society of Harrisburg Area, Inc. reserves the right to refuse adoptions.
- I/We give permission for the Humane Society of Harrisburg Area, Inc. and/or their agents to verify this information through any available means
- I/We certify that the aforementioned information is true and correct to the best of my/our knowledge.
Would you object to an authorized agent of the Humane Society of Harrisburg Area, Inc. inspecting the animal(s) and premises where the animal will be kept?*
- Yes
- No
Please enter your name below as your electronic signature

Dog Adoption Application

Step 1 of 6

Let's Get Started

Tell Us About Yourself

Tell Us About Your Home

Tell Us About Your Other Pets

Tell Us About the Pets You've Had Before!

Tell Us About Your Plans for This Dog

Personal References

Your Veterinarian

Acknowledgement & Release