Online Adoption Application

What type of pet are you looking to adopt?: *
 
Why do you wish adopt this pet?: *





 
Are you over the age of 18?: *

 
Do you live alone? : *

 
Ages of Adults?: *
 
Ages of Children?: *
 
Who will be responsible for the pet's care?: *
 
I live in a: *



 
I own/rent: *

 
Landlord Name:
Landlord Phone:
Does anyone in the home have allergies to animals?: *

 
What animals/breeds have you had in the past?: *
 
What animals/breeds do you currently have?: *
 
Are all animals in the household up to date on vaccines?: *

 
Can you show proof if necessary? : *

 
Will you be bringing any dogs from home to meet a pet?: *

 
How many hours a day will your pet be without human companionship?: *
 
Do you plan on leaving your pet?: *



 
Do you plan on leaving your pet outside?: *

 
If yes, please explain:
How many hours a day will your pet be outside?: *
 
What is the level of activity for your family?: *



 
Are your activities: *

 
How much grooming do you expect to do with this pet?: *
 
Are you able to provide preventative care (yearly vaccinations) and emergency care (for illness or injury) for this pet (estimated at $250-$300 a year)?: *

 
How often will you be visiting a vet each year?: *
 
Who is your vet now?: *
 
What vet have you used in the past?: *
 
Do you expect to move for any reason in the next 3 years?: *

 
Who will care for your pet if you cannot?: *
 
What circumstances would cause you to return your pet?: *
 
Are you ready to provide this pet with a permanent home for the rest of it's life, which can be 10-20 years?: *

 
Has a pet died in your home in the last 3 months?: *

 
If yes, from what?:
Have you adopted from CCHS before?: *

 
Under what name and address?:
Do you still have the pet?:

If no, what happened?:
**All medical costs incurred after adoption are the responsibility of the adopting party and not that of CCHS**: *
 
I certify the information I have provided is true to the best of my knowledge: *
 
Name: *
 
Drivers License Number: *
 
Date of birth: *
 
Home Phone:
Cell Phone: *
 
Address: *
 
Address (2):
Township (if applicable):
City: *
 
State: *
 
Zip: *
 
Email: *
  
Emergency Contact for Microchip (other than yourself): *
 
CCHS RESERVES THE RIGHT TO DENY ANY ADOPTION: