Chippewa Humane Dog Adoption Application

This application is to help us determine whether the adoption is in the best interest of the dog(s), as well as to assist you in finding the animal most compatible with you, your home, and your lifestyle. Thank you for taking the time to read and complete this application and go through our adoption process

Please fill out this application completely.

In order to be considered for an adoption you must:

Be 21 years of age & have verifiable identification.
Have knowledge & consent of all adults living in your household.
Have landlord's consent to bring an animal onto your property.
Understand that CHA has the right to deny or approve an application at its discretion.
Understand that applying does not guarantee approval nor does it reserve animals for you.
Understand that we process applications as quickly as possible, but the process can take several days to complete.

Complete all blanks on this form. Missing information will delay or disqualify your application.

Are you 21 or over? *

Yes No

Date of Birth *

Date

Name *

First AND Last Name Please

Primary Phone *

Secondary Person (if applicable)

Secondary Phone

Email Address *

example@example.com

Address *

Street Address

Street Address Line 2

City State

Zip

Time lived at this address *

Place of Employment

Occupation

Time with Current Employer

Are other people in your home experienced with dogs? *

Yes No

Does everyone in the house want to get a new dog? *

Yes No

Household activity level *

Quiet Active Very Active

Please list the names and ages of other members in your household:

Name 1

Age 1

Name 2

Age 2

Name 3

Age 3

Name 4

Age 4

Name 5

Age 5

Name 6

Age 6

Name 7

Age 7

Name 8

Age 8

Do you live in a: *

House Apartment Mobile Home (Own) Mobile Home - Which Park? Duplex Dorm Other

Do you: *

Own Rent Live with Family

If you rent or live with family: Landlord's Name

What is your Landlord's Phone Number

Landlord will be contacted to verify Pet Policy

Do you have the homeowner's permission to have a dog? *

Yes No

Are you aware of any restrictions that would prevent you from adopting a dog? *

No Restrictions Landlord Permission Insurance Policies Breed Restrictions Weight or size Restrictions

Pre-Adoption Questions (please answer all)

What type of dog are you looking to adopt? (If you know the name of the dog, list it here) *

Who is this pet being adopted for? *

Myself/My Family For friend as gift

Why have you decided to adopt? *

What will you do to ensure you will be a responsible owner? *

What do you know about the breed(s) you want to adopt (breed characteristics, potential health issues, etc.)? *

What happens if you get another animal that doesn't like this animal? *

What happens if it has accidents in the house? *

Do you plan to spay/neuter? *

Yes No N/A-already done

Do you plan to breed? *

Yes No N/A

Do any family members have allergies? *

Yes No

Have you applied to adopt from CHA or another animal shelter before? *

Yes No

If yes, when and where?

Have you ever brought an animal to a shelter? *

Yes No

If yes, why?

Have you ever given an animal to another person? *

Yes No

If yes, why?

Are there any life altering events in your near future (baby, moving, divorce, job layoff)? *

If you move in the future, what will you do with the dog? *

How will you exercise your pet? *

This dog will be alone without human companionship for about ____ hours per day *

Are you familiar with the specific needs of the breed you have chosen? *

Who will train the dog? *

Adopter Obedience class/Trainer Other

Are you comfortable doing some training with this dog to improve manners such as inappropriate jumping, housetraining, barking, pulling on the leash, digging, chewing, shyness/fear, etc.? *

If the dog you adopt is not house-trained, or needs basic skills to be a good companion in your home, what steps will you take? *

Are you willing to use a trainer? *

Yes No

What trainer will you use? *

It may take the new pet a month or longer to adjust to your home. Are you prepared for this adjustment period? *

Yes No

What problems would make you want to return the pet? (Check all that apply) *

How do you plan to deal with: • Food Aggression • Poor Manners • Barking • Housetraining • Mouthing / play biting • Scratching (furniture or people) • Climbing on furniture/counters • Chewing *

Are you willing to deal with unforeseen circumstances this pet may present? *

Yes No

This dog will live:

Inside Outside Inside & Outside

If you marked Outside, or Inside & Outside, please explain:

When not at home, the pet(s) will be: *

Crate Trained Free Roam of the House Outside Other

When outside, how will the dog be confined? *

Fenced Yard Harness & lead Covered fenced area Outdoor enclosure

Please describe the enclosure and note when they will be confined to it (during what hours of the day, and what times of year, etc. *

How experienced do you feel in securing veterinary care for a dog? *

No experience - but I am eager to learn! Some Experience - I know how to find a veterinarian I have a vet that I use and love! Other

In the box below, please list all pets you have owned in the last five years (including those no longer with you), and all pets currently living in the home (this includes pets belonging to roommates, etc.)

Animal 2

Animal 3

Animal 4

Animal 5

Animal 6

If you no longer have any of the pets listed above, please explain what happened to them:

* If you have not owned any pets in the last five years, and there are no pets currently living in the home with you, please check here: (you can leave the following section blank)

please check here:

Are your pets up to date with vaccinations?

Yes No I don't know

What Vet Clinic do you use?

What is your Vet Clinic's Phone Number?

What is the pet owner's name on the account at the vet clinic?

Are you aware of the state laws regarding licensing and vaccinations? *

Yes No

When adopting an unneutered or unspayed dog from CHA, it is required to have the dog spayed/neutered. Are you prepared financially and willing to comply with this policy? *

Yes No

Please Read Carefully and Sign: The undersigned applicant hereby grants the Chippewa Humane Association permission to confirm any information provided in this application with any appropriate third-party source, including landlords, veterinarians, etc. The information obtained will be held in confidence and used only by the Chippewa Humane Association for purposes of this adoption application. I certify that all the information on this application is true and complete. I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I also understand that this adoption application is at its own discretion. It is specifically understood that the Chippewa Humane Association reserves the right to deny any adoption application at its own discretion.

Signature

Clear

Date

Reference 1

Name and Number

Reference 2

Name and Number