Pet you are interested in adopting.

Residence Type: Single Family Residence Select From Drop down Condominium / Townhome Apartment Complex Mobile Home / Trailer Home

How many people live in your household?: Adults 1 2 3 4 5   Children 0 1 2 3 4 5

What are the ages of the Adults?:

What are the ages of the children under 18?:

Do all the Adults in the home know you are adopting a pet? N/A Y N

Do you own the home you are living in? N/A Y N

If you are renting can you provide proof of pet deposit? N/A Y N

Describe the type of fencing you have?

Why are you looking for a pet?

What other pets have you had and what happened to them?

Just let us know a little about your pet history and why they are / are not with you anymore. Were they indoor or Outdoor?

Are you pets up to date with their Vaccinations?

    Bordetella:     Y NA N

    Rabies:          Y NA N

    DHPPC:          Y NA N

Are your pets on Heartworm preventatives? Y NA N

Are your pets Spayed/Neutered? Y NA N

Vet Contact Information:

How many Hours a day will your pet be home alone? 0 1 2 3 4 5 6 7 8 9 10

Where will your pet be kept during the day? Hold " Ctl" button to select multiple

Crate Back Yard Take to Work Let Roam Free in house Garage Utility / Bathroom Dog House Day Care facility

Where will your pet be kept at nighttime? Hold " Ctl" button to select multiple

Crate Back Yard Take to Work Let Roam Free in house Garage Utility / Bathroom Dog House Day Care facility

What behaviors can you tolerate with a new pet?  Hold " Ctl" button to select multiple

Chewing Digging Barking Gets on Furniture Potty Accidents Begging

If no to any briefly explain how you would handle the problem?

Enter Solutions Here

What do you do with your pet when you leave town?

Neighbor / Friend / Family Crate Back Yard Take to Work Let Roam Free in house Garage Utility / Bathroom Dog House Day Care facility

Anyone in the Household allergic to dogs? N/A Y N

What happens to the pet if you have to move? Re-Home Take with me

How did you hear about our Organization?

Would you be interested in fostering for CCHS?  N/A Y N

Does anyone in the home require continuous mental or physical care?

Breifly explain if applicable

    By checking this box I certify that the information is truthful and accurate