Mikes chance animal rescue .com

Name of pet *

Full name *

First

Last

Date of Birth *

Why do you want to adopt the dog? (Please select at least one box)

Occupation *

Employer Name *

Spouse's/Partner's Occupation, Employer Name

Home Address (Street, City)*

Home Address (State, ZIP)*

How long at this address

Daytime phone *

Evening phone

Best time to call

Email address *

Link to your social media profile (Facebook, LinkedIn, Instagram, ect.) *

How many adults are there in your family (their relationship to you)? (if none, write n/a) *

How many children (ages)? (if none, write n/a) *

What type of home do you live in single family, townhome, apartment, etc.? *

Do you Rent or Own? *

Rent
Own

Do you have a yard? *

No
Fenced
Unfenced

How high is your fence?

Are there any slats/openings that could allow a small animal to get in/out?

Does your home have a pool?

No
Fenced
Unfenced

Please describe your household

If you rent, please give the rules governing pets and the landlord’s name and number

by providing this information you are allowing us to contact your landlord please inform them of this call so they will speak with us

Does anyone in the family have a known allergy to pets? *

Yes
No

Is everyone in agreement with the decision to adopt a pet? *

Yes
No

Do you have time to provide adequate love and attention? *

Yes
No

Please rate your dog training experience level. (1 being low, 5 being high) *

Please describe your animal training experience, and what breed dogs you've owned, if applicable. *

What other pets do you have (specify type, breed, and age), (if none, write n/a) *

Are these pets up to date on vaccines?

Yes
No

Are these pets spayed/neutered? If not, why?

Have you ever surrendered a pet? If so, why?

Have you ever had a pet euthanized? If so, why?

Have you ever lost a pet to an accident?

Yes
No

How do you discipline your pets and why? (describe)

Do you have a regular veterinarian?

Yes
No

Veterinarian’s name

Clinic name

Clinic address and phone number

providing us with this information you are allowing us to call your vet. Please call your vet and ask them to authorize the release of information.

Personal Reference: Name, Phone#, email *

How do you plan to exercise the dog? *

Where will the pet(s) spend the day? (describe)

Where will the pet(s) spend the night? (describe)

Number of hours (average) pet(s) will spend alone?

While left alone, pet(s) will be:

While left alone, pet(s) will be - Other (please explain):

What will you do with your dog(s) if you go on vacation? *

What will you do if your new dog(s) requires medical treatment exceeding your budget? What will you consider as unreasonable amount to treat a dog for disease or injury? *

Do you understand that sometimes a complete history and temperament of a rescue pet may not be known?

Yes
No

Do you understand that changing a pet’s environment may cause even a housebroken pet to have accidents and are you willing to take the time to housebreak a pet?

Yes
No

Who will have primary responsibility for this pet's daily care? (copy)

Who will have financial responsibility for this pet?

Do you agree to provide regular health care by a Licensed Veterinarian?

Yes
No

Do you agree to never declaw the pet (if you are adopting a cat)?

Yes
No

When the pet goes out, how do you plan to supervise it?

Under what circumstances would you not keep the pet? (Divorce, Illness, Moving, New Baby, Barking, Digging, etc.)

Which reasons are acceptable reasons for giving up your pet(s)? (please check at least one, and all that apply)

Why do you feel that you and your family and this particular dog are a good match? *

How would you deal with chewing? (be as detailed as possible) *

How would you deal with barking? (be as detailed as possible) *

How would you deal with digging? (be as detailed as possible) *

How would you deal with housebreaking/potty training? (be as detailed as possible) *

Do you agree to attend Formal Training classes with the dog? *

Yes
No

Do you agree to contact us if you can no longer keep this pet?

Yes
No

Will you be willing to let our representative visit your home by appointment?

Yes
No

How did you hear about us?

Agreement *

All of the information I have given is true and complete. This animal will reside in my home as a pet. I will provide it with quality pet food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccinations under the supervision of a licensed Veterinarian.*