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602-394-1595
2023 Impact Statement
CHANCE SHELTER ADOPTION APPLICATION
Tell us about you
Name
Address
State
Home Phone
Email address
(required)
Town/City
Zip
Cell
Name of Animal You Want To Adopt
Tell us about where you live
Do you:
Own
Rent
Live with Parents
Home Type
House
Duplex
Condominium
Apartment
How many pets are living in your household?
Animal type
Cats
Dog
Bird
Fish
Other
List pets owned now and in the past (most recent first).
Type
Pets name
Sex
Age
Spayed/Nuetered
Type
Pets Name
Sex
Age
Spayed/Nuetered
Type
Pet Name
Sex
Age
Spayed/Nuetered
Type
Pet Name
Sex
Age
Spayed/Nuetered
Type
Pet Name
Sex
Age
Spayed/Nuetered
Your Veterinarian
Name of your veterinary clinic:
City
Phone
Are your pets up to date with vaccinations?
Yes
No
If not, explain:
Under whose name, if not yours, is the animal registered at that clinic?
Your pet history
Have you ever adopted a shelter animal before?
Yes
No
Dog
Cat
Name
From where?
When?
Have you ever surrendered an animal to a shelter?
Yes
No
When?
Type of animal
Reason for surrender?
If yes, where?
Shelter feedback
How did you hear about Chance Shelter?
Friend/Word of Mouth
Website
Facebook
Other
If other
Adoption detail
Why do you want to adopt this animal?
Companion
Guard dog
Gift
Companion for another pet
Hunting
To breed
Personal protection
For children
Other
How many adults (over 18) are in your house?
Children?
Children’s ages?
Does any member of your family have any allergies to animals?
Yes
No
Are you:
Employed full time
Student
Employed part time
Unemployed
Retired
Other
If other, please explain
Is someone home during the day?
Yes
No
How many hours will this pet be alone per day?
Who?
Is your yard fenced? What type
When inside, how do you plan to keep your dog? Check all that apply:
Free inside house
Confined to crate
Inside a closed room
In the garage
When outside, how do you plan to keep your pet? Check all that apply
Fenced yard
Invisible fence
Tied/chained
Garage
Patio area
Outside dog run
Loose in unfenced yard
Leash and regular walks
Will cat be kept:
Indoor/outdoor
Indoor only
How do you intend to deal with:
Dogs
Housebreaking:
Chewing:
Fence jumping:
Barking:
Digging:
How do you intend to deal with:
Cats
Scratching/Clawing:
Biting:
If you move in the future, what will you do with your pet?
Are you familiar with the local animal (dog/cat) ordinances?
Yes
No
What type of identification do you plan to place on your dog/cat?
How much do you anticipate spending yearly to feed, vaccinate, register (license), and provide medical care for your pet?
Dogs/cats often live more than 15 years. Are you ready to take responsibility for the pet’s entire life?
Yes
No
if you are experiencing any problems with your new pet would you allow a staff member to evaluate in your home with prior notification?
Yes
No
By typing your full name below, I certify that the information I have given is true, and that I recognize that any misrepresentation of facts could prevent me from adopting a pet. I understand that Chance Shelter has the right to deny my request to adopt an animal, and I authorize investigation of all statements in this application.
Date
Submit
This field should be left blank
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