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Pocket Pals Adoption Form

Step 1 of 4

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Adopter Information
Adopter Name*
First Last
Date of Birth*
Month
Day
Year
Street Address*
Street Address Address Line 2 City State ZIP Code
Email*
Home Phone*
Cell Phone*

Household Info
Home Ownership
- Own
- Rent
- Other
Residence Type
Landlord Name
First Last
Landlord Phone
Does your home have an ultrasonic rodent repeller?
- Yes
- No
Have you ever adopted from the Lakeland Animal Shelter?
- Yes
- No
Does anyone in the household have allergies to animals?
- Yes
- No
If yes, can the allergies be controlled by medication?
- Yes
- No
Do all adults in your household know that you plan to adopt?
- Yes
- No
Number of Adults in Home
Number and ages of children in home

Are you adopting this animal as a (Check all that apply):
- House Pet
- Classroom Pet
- Companion for Other Pet
- Gift
- Outside Pet
- Breeder
Who will be the pocket pal’s primary caretaker? (i.e.: feed, train, monitor health, clean cage and/or litterbox, exercise, groom etc.):
What type(s) of pet(s) have you owned during the past five years?
Type/Breed Age Name Spayed/Neutered? (Yes/No) Still Own? (Yes/No)
If you no longer have the above pet(s), please explain what happened to them?:
If you have a veterinarian, please provide his/her name and the clinic name.
If there is a dog or cat in your household, has one of them ever injured or hunted another animal?
- Yes
- No
Cage Information for Your Pocket Pal
What type of cage will you have for your new pet?
What size cage will you have for your new pet?
Where will the cage be kept?
Name of Animal Interested in Adopting
Please tell us why you are interested in adopting this animal and why you feel they would be a good fit for your family.
Additional comments you want to share with us.
Please note, if you have specific questions you’d like answered before your visit to LAS, please call us at 262-723-1000.

Terms & Conditions
I certify that I am at least 18 years of age and the information I have given is true. I recognize that any misrepresentation of facts may result in my losing the privilege of adopting a companion animal and I understand that the Lakeland Animal Shelter has the right to deny my application.

I am fully aware that I am adopting a living creature and as such that the Lakeland Animal Shelter is unable to guarantee the health of the animal.

If this animal becomes ill, I certify that I am financially and/or emotionally prepared to treat this animal at my own expense.
I have read and agree to the terms and conditions.*
- Agree
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Comments
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3615 State Road 67
Delavan, WI
P.O. Box 1000
Elkhorn, WI 53121
(262) 723-1000
(262) 723-1001
Mon - Fri: 12PM - 5PM
Sat: 11AM - 4PM

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/ Wisconsin Dog Seller's Permit #268467-DS
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