Break The Chains Adoption Application

Break The Chains Rescue is an all-volunteer, non-profit, animal welfare organization dedicated to the rescue and placement of neglected and abused animals. All of our pets receive complete medical care, which includes worming, vaccinations, and spaying/neutering prior to their adoption.

This questionnaire is designed to help Break The Chains Rescue and yourself determine if a specific dog is the right one for you and your household. All adopting parties are required to complete this form prior to adoption. The Break Chains Rescue reserves the right to deny any adoption based on answers to this questionnaire and/or interviews prior to adoptions!

Break The Chains Rescue has provided initial vetting, spay or neuter, and will provide vet records at time of adoption.

Name of the dog you are interested in:*

Your full name:*

Your age:*

Street Address:*

City, State, Zip*

Home Phone:

Area CodePhone Number

Work Phone:

Area CodePhone Number

Cell Phone:

Area CodePhone Number

E-mail:

Employer:

Character reference and phone number:

Are all members of your household in agreement with this adoption?*

YesNoDon't Know

Who will be the pet's primary caregiver?*

Do you live in a*

Do you own or rent?*

OwnRent

If rent, provide name and phone number of landlord:

Does your landlord allow dogs?

YesNo

Are there any restrictions from your landlord or subdivision?*

Number of petsSize or weight restrictionsBreed restrictionsNone

Do you have a fully fenced yard?*

YesNo

Height and type of fence

Do you have any of the following?

Underground fenceKennelDog Run

How many adults are in your household?*

How many children are in your household?*

If children, what are their ages?

Have your children been around animals before?

YesNo

Does anyone in your home have allergies to dogs or have asthma?*

YesNo

List any pets you own or have owned in the past five years, and their ages

How many of these pets are spayed/neutered?

Where are these animals now?

Have you adopted from an animal welfare group before?

YesNo

If yes, what group?

Have you ever given up a pet?

YesNo

If yes, what were the circumstances?

Please provide the name and phone number of your current and/or previous veterinarian or clinic:

What type of personality do you want your pet to have? (i.e. calm, energetic, protective, couch-potato)*

Are you aware of crate training?*

YesNo

Have you ever house-broken a dog or puppy before?*

YesNo

If the dog has an "accident" in your home, what type of correction do you plan to use?*

How many hours each day will your new pet be home alone?*

Where will your new pet sleep at night?*

How will you supervise the dog's outdoor activity?*

Where will your new dog stay when nobody is home?*

What length of time will you allow your new pet to adjust to his new home?*

Are you willing to work through your new pet's issues, if any?*

YesNo

Are you aware that a new environment is stressful for your pet, and they may exhibit uncharacteristic behavior?*

YesNo

Do you understand that a dog can be an 18 year commitment, and can cost $300 - $500 per year to care for?*

YesNo

Do you plan to take an obedience class with your dog?*

YesNoNot sure

If yes, where?

Are you aware that a large breed dog takes about two years to mature? Is this something you're prepared for?*

YesNo

What circumstances would lead you to give up your new dog?*

If you had to give up your dog, what would you do with him/her?*

How did you find out about Break The Chains Rescue?*

I understand that I assume full responsibility for the welfare of this pet from the date of adoption.

APPLICATION ACKNOWLEDGEMENT

By signature below, I acknowledge that I am at least 18 years of age, and I have truthfully answered all questions and provided correct information on this application to the best of my knowledge. As the adoption applicant, I understand BTCR is a private corporation which reserves the right to refuse or deny adoption privileges to any applicant for any reason, without explanation or cause. I acknowledge that BTC adoption decision is final. I understand that the preliminary adoption application process involves the full completion of an adoption application, execution of an adoption contract, reference follow-up, background check, and either a home visit or video submission. I understand that additional information may be requested to assist in the final adoption decision by BTC. I understand that should I adopt a dog from BTCR, and any of the provided applicant information listed be false and/or a misrepresentation of the facts as determined by BTC, I agree to immediately relinquish ownership of the dog back

Authorization for Background Inquiry and Release of Information

By signature acknowledgment, I also authorize BTC and/or the consumer reporting Agency of its choice, to retrieve information from all references, individuals, government agencies, companies, corporations, law enforcement agencies in the federal, state, or county level relating to my past activities, to supply any and all information concerning my background, and release the same from any liability resulting in providing such information. The information received may include, but is not limited to residential, criminal records, veterinary records and verbal interviews attesting to the adopter's character, residence, and/or mode of living. If pulled I may request a copy of any report that is prepared regarding me and may also request the nature and substance of all information about me contained in the files of any reporting agency. I understand this request should be in writing directly to BTC describing specific information

Representation

The adopter represents they have not previously been charged or currently have open investigations or been convicted of animal cruelty for dog fighting, dog training, animal abandonment or animal neglect within any U.S. State or its Territories. The adopter represents they have not previously or currently been charged or convicted of domestic violence, abuse or neglect within any U.S. State or its Territories and are not receiving treatment / counseling for previous charges, convictions or concerns related to domestic violence.

In addition, the adopter represents they are not adopting the dog on behalf of a family member or acting as an agent of any individual charged or convicted of animal cruelty for dog fighting, dog training, animal abandonment or neglect.

Adopter Signature:

BTC does not discriminate against any adoption applicant based on race, color, religion, sex including pregnancy an gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, of other non-merit factor.

Signature

Date

Break The Chains Adoption Application

Applicant Information

Household Information

Current/Previous Pet Information

New Pet Information