Adoption Application

Applicant name

Street address

City

Phone number

Your email

Do you currently have any pets?
YesNo

If yes, please list name, age, species, and size:

Are your pets spayed/neutered and up-to-date on vaccinations?
n/ayesno

Please list the number of adults living in the household:

Please list the number and ages of the children living in the household:

Have you owned a pet before?
YesNo

Do you live in a house, apartment, condo, military housing, or other? Please specify.

Do you have a fenced-in yard?
yesno

Where will the pet be kept when you are home?

Where will the pet sleep at night?

Where will the pet be kept when left alone?

Does anyone in the home have allergies to animals?
yesno

Are you willing to give the pet time to adjust to a new environment?
yesno

Personal Reference

Please give us the contact info for one reference. This could be your current pet’s veterinarian, staff or volunteer of an animal welfare group, or simply a character reference..

Name of Reference

Email address of reference

Phone number of reference

Application Agreement

Cornerstone Hospice Pet Peace of Mind Program reserves the right to refuse any prospective adoption applicants.

By giving your signature you attest that all information above is true and correct and that you give permission to Cornerstone Hospice Pet Peace of Mind Program to check your references which may require disclosure of information that you have provided in this application or that you have given via email or conversation to the people you have listed as references, including, but not limited to your landlord/condo association and veterinary office.

Cornerstone Hospice Pet Peace of Mind Program does not ask for an adoption “fee” however, donations are greatly appreciated and support the program in its efforts to help keep pets in the homes of patients and families in the care of Cornerstone Hospice.

Please type your initials as your digital signature