Adoption Application

Adoption Questionnaire

Date(*)
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Animal Type(*)
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Animal ID No.
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Last Name(*)
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First Name(*)
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Address(*)
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City(*)
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State(*)
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Zip Code
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Email Address
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Home Phone Number(*)
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Cell Phone Number
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I live in(*)
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Number Of Adults Living in This Household(*)
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Number of Children in Household
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Children Age Range
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If you are not familiar with pet responsibility laws in your area, please visit wcasrock.org
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Have you ever brought an animal into a shelter and if so why
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How Many Cats In Home
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How Many Dogs In Home(*)
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Enter name and description of each animal above
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Why are you interested in adopting this animal (one word)
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How often will this pet be outside
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Are you familiar with the needs of this specific Breed(*)
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What is the name of your veterinarian or veterinary clinic or would you like a referral
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How Did You Hear About Us(*)
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We will explain the medical and behavior on this pet. Check additional topics you would like information on
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By signing below, I certify the information I have given is true, I am at least 18 years old, and that I understand any misrepresentation of facts may result in losing my privilege of adopting a pet through Winnebago County Animal Services. I also understand that Winnebago County Animal Services has the right to deny my request to adopt an animal, and I authorize investigation of all statements in this questionnaire
Digital Signature(*)
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OFFICE USE ONLY Date:________________ Staff Member:______________________ ___Approved ___Denied Reason Denied:________________________ ________________________ Verifiable Identification:____________ Animal ID Number: A____________ Comments:___________________________________________________________________________________________________
After your questionnaire has been reviewed by our staff, it will either be approved or denied in conjunction with our approval guidelines. A representative will contact you to let you know if you are approved, denied, or if we need more information. Thank You.
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Winnebago County Animal Services
4517 North Main Street
Rockford, IL 61103
P: 815-319-4100
F: 815-319-4101

Shelter Hours:
Monday: 11:00 AM - 7:00 PM
Tuesday-Friday: 11:00 AM - 5:00 PM
Saturday: 11:00 AM – 4:00 PM
Sunday: CLOSED
*Please note, all adoptions end 30 minutes prior to closing.

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