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Invalid Submission Values
Chautauqua County Humane Society Online Adoption Application
**IF THE CAT YOU ARE LOOKING AT SAYS "ADOPT ME AT PETSMART" YOU DO NOT HAVE TO FILL OUT AN ONLINE APPLICATION. APPLICATIONS ARE HANDLED IN THE STORE. THANK YOU**
What type of pet are you looking to adopt?
(required)
Why do you wish adopt this pet?
(required)
Companion for self
Companion for child
Companion for other pet
Companion for other person
Hunting dog
Guard dog
Are you interested in a specific animal. Please put name of animal
Are you over the age of 18?
(required)
Yes
No
Do you live alone?
(required)
Yes
No
Ages of Adults?
(required)
Ages of Children?
Who will be responsible for the pet's care?
(required)
I live in a
(required)
House
Apartment
Mobile Home
With Parents/other
I own/rent
(required)
Own
Rent
Landlord Name
Landlord Phone
Does anyone in the home have allergies to animals?
(required)
Yes
No
What animals/breeds have you had in the past?
(required)
What animals/breeds do you currently have?
(required)
Are all animals in the household up to date on vaccines?
(required)
Yes
No
Can you show proof if necessary?
(required)
Yes
No
Will you be bringing any dogs from home to meet a pet?
(required)
Yes
No
How many hours a day will your pet be without human companionship?
(required)
Do you plan on leaving your pet?
(required)
Alone in the house
In a crate/cage
Confined to a room/area
Run of the house
Do you plan on leaving your pet outside?
(required)
Yes
No
If yes, please explain
How many hours a day will your pet be outside?
(required)
What is the level of activity for your family?
(required)
Quiet
Average
Active
Hectic
Are your activities
(required)
Mainly indoor?
Mainly outdoor?
How much grooming do you expect to do with this pet?
(required)
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)?
(required)
Yes
No
How often will you be visiting a vet each year?
(required)
Who is your vet now?
(required)
What vet have you used in the past?
(required)
Do you expect to move for any reason in the next 3 years?
(required)
Yes
No
Who will care for your pet if you cannot?
(required)
What circumstances would cause you to return your pet?
(required)
Are you ready to provide this pet with a permanent home for the rest of it's life, which can be 10-20 years?
(required)
Yes
No
Has a pet died in your home in the last 3 months?
(required)
Yes
No
If yes, from what?
Have you adopted from CCHS before?
(required)
Yes
No
Under what name and address?
Do you still have the pet?
Yes
No
If no, what happened?
**All medical costs incurred after adoption are the responsibility of the adopting party and not that of CCHS**
(required)
Agree
I certify the information I have provided is true to the best of my knowledge
(required)
Agree
Name
(required)
Today's Date
(required)
Example: ##/##/####
Drivers License Number
(required)
Date of birth
(required)
Home Phone
Cell Phone
(required)
Address
(required)
Address (2)
Township (if applicable)
City
(required)
State
(required)
Select an option
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
(required)
Email
(required)
Example: janedoe@fakeemail.com
Emergency Contact for Microchip (other than yourself)
(required)
Where did you see this pet listed
(required)
CCHS RESERVES THE RIGHT TO DENY ANY ADOPTION
PLEASE CLICK THE SUBMIT BUTTON ONLY ONCE AND THEN WAIT FOR THE FORM TO PROCESS. THANK YOU.