First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone*

Cell Phone*

Please list your age range: *Our minimum age requirement for adoption is 21. 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 80+ *
Choose one: 18-20 20-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 80+

Which Animal are you Interested in? If you would like to Foster, please select "Foster" in the drop-down menu.
Choose an animal: Autumn Bailey Brownie Chile Cinnamon Cora Dog Walker Volunteer I'd Like to Foster! Jacks Logan Lola Lucy Maggie Matcha Max Rocky Undecided Unlisted Dog

If the first pup you selected is unavailable, do you have a follow up selection?
Choose an animal: Autumn Bailey Brownie Chile Cinnamon Cora Dog Walker Volunteer I'd Like to Foster! Jacks Logan Lola Lucy Maggie Matcha Max Rocky Undecided Unlisted Dog

Why are you interested in adopting a pet?*

Names (First/Middle/Last) & AGES of All Household Members: If none, type NA*

Does everyone in your household agree on adopting?*
Choose one: Yes No

Does anyone in your home have allergies to pets?*
Choose one: Yes No

Do you:*
Choose one: Rent Own Neither

Home Type:*
Choose one: Apartment Condo Duplex Single Family Home

HOA or Leasing Officer Information: Name, Phone Number/Email

How long have you lived at your current residence?*
Choose one: Less than a Year 1-5 Years More than 5 Years

Is your yard fully fenced?*
Choose one: Yes No

What type of fence do you have? (style/height)

Do you have other pets at home?*
Choose one: Yes No

If yes, please list all pets currently in your home. Name, age, type.

Are your current pets spayed or neutered? (Spaying/neutering of all pets in your home is required unless otherwise documented by a veterinarian.)
Choose one: Yes No

If your pet is not altered, please explain why. Is this information documented on your veterinarian record?

Are your current pets up to date on vaccinations? Note: Current Rabies & Distemper (DHPP or some variation) is required of all dogs in your household unless deemed unnecessary by a veterinarian.
Choose one: Yes No

Do you/ have you used Heartworm & Flea/Tick Preventative?
Choose one: Yes No

Please list all deceased pets within the last 15 years. Name/ age deceased/ year deceased, and cause (if known).

Who is your primary pet physician? If none, type NA. If your pet is deceased, who is the last veterinarian to have vaccine records of your past pet?*

What is the pet physician's phone number? (Type 000-000-0000 if you do not have pets in your household.) This field IS required if you have pets in your household. *Many vets office REQUIRE your approval prior to releasing medical information. Please call your vet to verify. Not providing advance approval with your vet does delay the process. (The following list of offices DO REQUIRE YOUR APPROVAL: Adamstown, Antietam, Animal Care Center: Danville, Wyomissing, VCA Sinking Spring, ARK, Oley Valley, Conestoga, Douglassville, Pocono Peak, Humane Pennsylvania. This list is NOT all inclusive.)*

Have you or anyone in your household ever surrendered a pet before?*
Choose one: Yes No

If you have surrendered a pet, please explain why:

Describe the most important characteristics you are looking for in a pet:*

Where will this pet spend most of its time?*
Choose one: Indoors Outdoors Both

Where would this pet sleep?*

Where would this pet stay when you are not at home?*

On average, how many hours would this pet be alone daily?*

Are you open to hiring a dog trainer or dog walker if it is recommended?
Choose one: Yes No

Please provide 2 NON FAMILY personal references. Friends, co-workers, neighbors, dog groomers/walkers, etc., are appropriate. (please do not list individual that are related to each other, such as husband and wife. Please do not list immediate extended family, such as in-laws. Please do not list current boyfriends/girlfriends/partners.): Name/ Phone/ Email *

I was referred to PA PitStop by:

Are you interested in volunteering and/or fostering?*
Choose one: Yes No

I understand that if I am unable to keep my pet for any reason, the pet MUST be returned to PA Pit Stop Animal Rescue:*
Choose one: Yes No

I understand that I am applying for be approved to adopt from PA PitStop. Once approved, I will remain approved and can adopt again or at a different time. I understand that stipulations may be made based on my specific situation (ie: not approved to adopt a bully breed due to lease agreement). I understand that while I have selected my dog of interest, that I am, in no way, being promised adoption of this specific dog. I understand that if the dog I selected is unavailable for any reason, it is my choice to consider another dog.*
Choose one: Yes No

If not already altered at the time of adoption, I understand that alteration is required and no exceptions will be made. If my pet is not altered at the time of adoption, I understand the Rescue will arrange and pay for this surgery at the clinic of the Rescue's choice. I will be responsible to bring my pet to that appointment, provide proof of rabies vaccination, and provide the appropriate follow up care.*
Choose one: Yes No

I understand that a non-refundable $10 fee accompanies this application. This $10 will be applied as a credit towards my adoption fee. I understand that I will be prompted to pay this fee by an adoption counselor during the application process. The fee will be requested after the general background check is complete, but before references are contacted. Applications will be discontinued without payment. Payment is due via Venmo.

I understand that adoption fees range from $250-$600, but the "standard" adoption fee is currently $600. This includes spay/neuter of my pet at the Rescue's approved clinic. I understand that, once approved, I will be asked to pay a $300 nonrefundable deposit. This deposit goes towards the adoption fee. I agree to pay the adoption fee associated with my pet.*
Choose one: Yes No

I understand that a home check (virtual or in person) will be required as part of this application process. *
Choose one: Yes No

I verify that I am 19 or older, and that the above information is accurate. I understand if I have made false or misleading statements, that my application will be disqualified. Applicants under 19 may be asked to be accompanied by an adult. Signature (type name): *

Date Signed: *