First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone*

Work Phone
x

Cell Phone*

Alt Email

Today's Date:*

Adopter's Date of Birth:*

Drivers License Number:*

State of Drivers License:*
Choose one: AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware DC District of Columbia FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington WV West Virginia WI isconsin WY Wyoming

Have you adopted a pet from Camp Chaos previously?
Choose one: Yes No

If so, when?

Does EVERY member in the home know and agree with the adoption of this animal?*
Choose one: Yes No

What is the Name of the Animal being applied for?*
Choose an animal: Cookie FOSTER Itty-Bitty Peewee Sid Teensy-Weensy

Do you presently own any pets?*
Choose one: Yes No

If you do currently own pets, how many and what kind?

If you currently own pets, are they up to date on vaccines?
Choose one: Yes No

If you currently own pets, are they all Spayed and/or Neutered?
Choose one: Yes No

If you currently own pets, do you have them on Heartworm and Flea/Tick preventative medication?
Choose one: Yes No

If you have other pets, what brand of heartworm preventative do you use?

If you have other pets, what brand of flea and tick preventative do you use?

Are you able to provide proof of current vaccines and heartworm / flea & tick preventative at the time of adoption?
Choose one: Yes No

If you currently own pets, please provide the Name, Address and Telephone Number for your current Veterinarian Office.

Which do you live in?*
Choose one: House Mobile Home Apartment Condo

Do you own your home?*
Choose one: Yes No

If you rent your home, does your landlord allow pets and have you notified them of your intent to adopt?
Choose one: Yes No

If you are renting, what is the phone # to reach your landlord?

Are there children presently living in the home?*
Choose one: Yes No

If there are children in the home, what are their ages?

Have you ever surrendered or rehomed a pet before?*
Choose one: Yes No

If you have surrendered or rehomed a pet, please describe the situation.

How do you plan to provide for your pet if you are out of town?*

What would you do with your pet if you were forced to move?*

Are you prepared for veterinary expenses such as emergency medical problems (especially in old age) that can be quite costly, and that can be incurred at any time during the entire life of this pet?*
Choose one: Yes No

Are you willing to live with a pet that can be destructive at times?*
Choose one: Yes No

Which of the following reasons would prompt you to give up your pet?

Where will the pet spend the majority of its time?*

What is your current occupation?*

What is your Place of Employment? Please include Business Name, Address and Phone #*

Please provide 2 personal references. Include a phone number where they can be reached.*

This application is not a guarantee for adoption of the pet. Applications for each animal will be reviewed and the pet will be placed in the best forever home based on the pet's needs. Camp Chaos Puppy Rescue reserves the right to refuse adoption to any applicant for any reason. You must be 21 years old to adopt an animal from Camp Chaos Puppy Rescue. I certify that all information on this application is true and correct. I understand that the adoption donation is Non-refundable. Please Sign and Date Below:*

I hereby agree that I am over the age of 21 years and that I am able to provide the resources necessary for the proper care of the animal. Initials:*

I hereby certify that I have never been charged or convicted of animal abuse or neglect. Initials:*

I hereby agree to care for the pet listed on my application in a humane and responsible manner by providing clean and adequate shelter, food, water and veterinary care. I further agree that said pet shall reside inside my home and not be allowed to roam freely. Initials:*

The animal being adopted has been examined by Camp Chaos Puppy Rescue and a veterinarian prior to adoption and has received appropriate immunizations. I understand that Camp Chaos Puppy Rescue does not hold representations or warranties regarding the animal's health, physical condition, or age after the date on the adoption contract. I understand that health problems may arise with this animal; including serious illnesses requiring emergency care or surgery, and that it is my sole responsibility to seek veterinarian care in a timely manner and to pay any related costs. Initials:*

I hereby agree, if I currently own other pets, I will provide proof of current vaccinations and heartworm / flea & tick preventative within 3 days of adoption. If not provided, I agree, my adoption fee will be forfeited and the adopted animal will be reclaimed by a Camp Chaos representative. Initials:*

I hereby agree that the adopted animal shall not be subjected to any form of cosmetic surgery or alteration including, but not limited to, ear cropping, tail docking, declawing, removal of rescue microchip etc., unless deemed medically necessary by a veterinarian. Such procedures are extremely painful and typically not necessary. Initials: *

I hereby agree that Camp Chaos Puppy Rescue or any authorized individual acting on its behalf may examine or make inquiry about the adopted pet at any time, with or without notice. If said examination or inquiry demonstrates that the pet is not being cared for in a manner wholly consistent with the above representations and/or the representations made by myself on the Application, I agree that Camp Chaos Puppy Rescue, or any authorized individual acting on its behalf, may reclaim the pet and place it in another home without payment or compensation. If contact is made via phone, I agree to make a good faith effort to return Camp Chaos Puppy Rescue's call as soon as possible. Initials: *

I understand that the adoption donation is NON-REFUNDABLE. Initials:*

I hereby agree that I will keep the pet for as long as it shall live and will not transfer the ownership or custody of the pet to any other person or to any business or organization other than Camp Chaos Puppy Rescue except for the purposes of veterinary treatment and/or temporary lodging of the animal. If I can no longer keep the animal, I will notify Camp Chaos Puppy Rescue IMMEDIATELY and will work with them to place the animal in an approved home. I understand the adoption fee will not be refunded. Initials:*

Camp Chaos Puppy Rescue reserves the right to reclaim said animal if it is found at large or not in compliance with the terms of this contract or local animal control laws, voiding this adoption contract and any rights of ownership. I will pay legal or other fees in the event Camp Chaos Puppy Rescue must reclaim the animal due to my failure to comply with the terms of this contract. I authorize Camp Chaos Puppy Rescue, in its sole discretion to determine whether said pet will be reclaimed and adoption terminated if conditions of this contract are not upheld. No refund will be given if animal is reclaimed for my failure to comply. Initials:*

Applicant Signature and Date:*