Online Adoption Application




What type of pet are you looking to adopt?: *
Why do you wish adopt this pet?: *

Are you interested in a specific animal. Please put name of animal:
Are you over the age of 18?: *

Do you live alone? : *

Ages of Adults?: *
Ages of Children?:
Who will be responsible for the pet's care?: *
I live in a: *

I own/rent: *

Landlord Name:
Landlord Phone:
Does anyone in the home have allergies to animals?: *

What animals/breeds have you had in the past?: *
What animals/breeds do you currently have?: *
Are all animals in the household up to date on vaccines?: *

Can you show proof if necessary? : *

Will you be bringing any dogs from home to meet a pet?: *

How many hours a day will your pet be without human companionship?: *
Do you plan on leaving your pet?: *

Do you plan on leaving your pet outside?: *

If yes, please explain:
How many hours a day will your pet be outside?: *
What is the level of activity for your family?: *

Are your activities: *

How much grooming do you expect to do with this pet?: *
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)?: *

How often will you be visiting a vet each year?: *
Who is your vet now?: *
What vet have you used in the past?: *
Do you expect to move for any reason in the next 3 years?: *

Who will care for your pet if you cannot?: *
What circumstances would cause you to return your pet?: *
Are you ready to provide this pet with a permanent home for the rest of it's life, which can be 10-20 years?: *

Has a pet died in your home in the last 3 months?: *

If yes, from what?:
Have you adopted from CCHS before?: *

Under what name and address?:
Do you still have the pet?:

If no, what happened?:
**All medical costs incurred after adoption are the responsibility of the adopting party and not that of CCHS**: *
I certify the information I have provided is true to the best of my knowledge: *
Name: *
Today's Date:
Drivers License Number: *
Date of birth: *
Home Phone:
Cell Phone: *
Address: *
Address (2):
Township (if applicable):
City: *
State: *
Zip: *
Email: *
Emergency Contact for Microchip (other than yourself): *