Adoption Application

Thank you for taking the time to fill out this application. Your information will remain confidential and used only as part of the Second Chance Chi Rescue Adoption Program.

All fields marked (REQUIRED) must be filled in or your application will not go through. To save time on the phone when we call you, make sure you fill this application out in its entirety so we won’t have as many questions when we talk.

ATTENTION!!

All applications are processed on a first-come, first-serve basis. If you decide to put in an application and request a meet and greet and someone else puts in an application before you, their application will be processed first.

If you qualify to adopt from us and are the best fit for the dog you are applying for due to the information on your application and you are chosen to proceed with the adoption, there will be a $50.00 non-refundable deposit to move forward.

If you adopt the dog you are applying for, the deposit will go towards the adoption fee. If you back out halfway through the adoption process and decide you changed your mind, you forfeit your deposit as a donation to the rescue.

We apologize that it has come down to this however, we have had too many people start the adoption process only to decide halfway through the process that their significant other isn’t ready or landlord will not let them have a pet or something that should have been worked out before starting the process.

(So be 100% sure you are wanting and able to adopt a dog before starting the process.)

Applicant Information

Name: (REQUIRED)

First

Last

Address: (REQUIRED)

Street Address City State / Province / Region Postal / Zip Code Country

Main Contact Phone Number: (REQUIRED)

Area Code

Phone Number

E-mail: Must use a monitored email to receive a copy of this application. (REQUIRED)

Driver License Number and State Issued: (REQUIRED)

Occupation: If retired, Place retired here and move to Section 2. (REQUIRED)

Employment Address: (Not Required if Retired)

Street Address City State / Province / Region Postal / Zip Code Country

Employer's Phone Number:

Area Code

Phone Number

Spouse / Sig Other Children / Roommates

Spouse's Name and Age:

Children's Ages:

Roommate (s): Names and Ages. (One Per Line)

Residence Information (A letter from your landlord or apartment manager will be required if you rent.)

Do you own or rent your residence: (REQUIRED)

Own

Rent

How long at current residence: (REQUIRED)

If renting, do you have permission from the landlord/property owner to own a pet:

Yes

Landlords Name:

First

Last

Landlords Phone Number:

Area Code

Phone Number

Describe your yard: (Give as much detail as possible) IE: Fence Height, Gate, Size of yard. We will also evaluate your yard on our home visit. (REQUIRED)

Personal References (All personal references will be checked)

Personal reference #1 name: (REQUIRED)

First

Last

Personal reference #1 phone number: (REQUIRED)

Area Code

Phone Number

Personal reference #2 name: (REQUIRED)

First

Last

Personal Reference #2 phone number: (REQUIRED)

Area Code

Phone Number

Personal reference #3 name: (REQUIRED)

First

Last

Personal reference #3 phone number: (REQUIRED)

Area Code

Phone Number

Veterinary References (All Vet references will be verified)

Vets Name: (REQUIRED)

First

Last

Name Of Vet Clinic: (REQUIRED)

Vets Address: (REQUIRED)

Street Address City State / Province / Region Postal / Zip Code Country

Vets Phone Number: (REQUIRED)

Area Code

Phone Number

Present and Past Pet History

Describe each past pet for the last 5 years, one per line: (Name, Age, Sex, Breed, Altered, Time Owned, Reason No Longer Owned)

Have you ever had a dog euthanized:

Yes

If yes to above question please explain here:

Training & Disclipine

Do You Have Experience With Dog Training:

Yes

If yes to above question, please explain:

What Method Will You Use To Housetrain Your Dog:

Discipline's Used If Your Dog Misbehaves And What Would You Do If The Behavior Continued:

General Questions

Which Of The Following Discipline's Will You Use If Your Dog Just Won't Listen:

Can You Afford Regular Veterinary Care For This Dog - Including Yearly Vaccinations, Annual Physical Exams, Dental Care, Etc:

Yes

Can You Afford Serious Injury Or Illness Costs? ($1,000.00 Or More):

Yes

Do any members of your household have any allergies to animals:

Yes

If yes explain:

Who will be financially responsible for the pet:

Any other information you would like us to know to improve your chances of being approved to adopt a dog from Second Chance Chi Rescue:

About The Dog You Want To Adopt

Dogs Name / ID#:

Size Preference:

Xtra Small (2-5 lbs)

Small (5-9 lbs)

Medium (9-15 lbs)

Large (15-20 lbs)

Breed Of Dog:

Chihuahua

Chihuahua Mix

Other Small Breed Under 20 lbs

If you choose Other Small Breed Under 20lbs from above please explain:

Agreement And Signature (All fields Required)

Do you agree to provide regular health care by a Licensed Veterinarian: (REQUIRED)

Yes

Do you agree to keep the dog as an indoor dog: (REQUIRED)

Yes

Do you agree to contact and surrender this dog back to Second Chance Chi Rescue if you can no longer keep this dog: (REQUIRED)

Yes

Are you willing to let a representative of Second Chance Chi Rescue visit your home by appointment for a home check to make sure your home is the right fit for our dog: (REQUIRED)

Yes

If you adopt one of Second Chance Chi Rescues dogs, do you agree to update them with photos for at least six months after adoption on their facebook page: (REQUIRED)

Yes

Do you agree that any and all funds donated to or placed on a dog for adoption is not refundable for a animal returned that is no longer wanted or able to keep: (REQUIRED)

Yes

If you adopt one of Second Chance Chi Rescues dogs, do you agree to give them complete access to the dog's records with the veterinarian responsible for the care of the dog?: (REQUIRED)

Yes

If you adopt one of Second Chance Chi Rescues dogs that is too young to be spayed/neutered at time of adoption do you agree to get it spayed/neutered when it reaches the appropriate age and contact us with the information: (REQUIRED)

Yes

You agree that Second Chance Chi Rescue may take the dog back or ask for its surrender if the dog is not getting the care that is agreed upon by our adoption terms: (REQUIRED)

Yes

I accept this dog as my companion pet if Second Chance Chi Rescue accepts my offer to adopt the dog. I have agreed to offer a tax-deductible, non-refundable donation or adoption payment of $200.00 or $300.00 (For dogs under 1 year old) to assist with the payment of prior veterinary care for the dog, as well as helping Second Chance Chi to rescue more dogs in the future.

In consideration for adopting the dog, I agree to the following adoption conditions.

To accept and consider this dog as a household companion and to provide this dog with humane care and treatment, including proper food, water, shelter and exercise, and to give this dog a reasonable amount of time to adjust to its new home.
To register the dog with, and obtain a dog license from the municipality where I live, or as required by law.
To safeguard the dog from loss or mishap. This means not allowing the dog to run at large unsupervised, and keeping the dog at all times at the premises listed as our address.
If the dog is lost or stolen, to immediately notify Second Chance Chi Rescue at the emergency contact information given within the adoption papers, and to make every reasonable effort to recover the dog by contacting all local shelters, pounds and centers for Animal Care and Control centers.
NOT to give or sell the dog to another person, relative, or any other individual, or any other rescue group, humane association, shelter or pound, or any medical or experimental laboratory, or any organization.
NOT to alter the dog’s appearance in any way, shape or form (e.g. cropping, docking).
To immediately notify Second Chance Chi Rescue in the event of death and prior to disposal of the dog’s body.
To allow a Second Chance Chi Rescue representative to make periodic visits to my home during the first 90 days following the signing of this agreement.
To immediately notify Second Chance Chi Rescue of any change in address or telephone number and of any change in circumstances that may prevent me from keeping the dog, or to comply with any of the terms and conditions contained herein.
After 30 days, To immediately contact Second Chance Chi Rescue to arrange for them to help re-home the dog in the event that I, or my immediate family members charged with care of the dog, cannot keep the dog and provide the care set forth in Paragraph 1(a) for any reason. Under no conditions, shall I surrender the dog to a shelter or euthanize the dog, except if a licensed veterinarian determines that the dog is terminally ill, or is suffering from a medical condition for which the licensed veterinarian advises euthanasia.

2. I understand that the dog has been checked, spayed/neutered and vaccinated by a licensed veterinarian and that his/her state of health is accurately represented to the best knowledge of Second Chance Chi Rescue. Any and all medical attention that has been deemed necessary has been done. I understand that any further medical attention desired must be at my own expense. Second Chance Chi Rescue suggests that I have the dog examined by my own veterinarian within seven (7) days of adoption, and if it is determined that the health of the animal is not satisfactory, I may return the dog.

3. I am aware that the educated opinions of the Second Chance Chi Rescue staff do not constitute a claim or guarantee as to the absolute age, temperament, health, or mental disposition of any animal available for foster or adoption. With that in mind, I hereby accept possession, legal guardianship, and responsibility for the animal I am adopting, and discharge Second Chance Chi Rescue forever from liability for any injury or damage to any person or property caused in the future by said animal, and from any causes of action, claims, suits, or demands whatsoever that may arise as a result of such injury or damages. Second Chance Chi Rescue is in no way responsible for any future training or medical issues that may occur post adoption.

4. I have read and fully understand the terms and conditions of this agreement, and agree that it is not arbitrary and is common in pet adoption contracts. I further understand that if I fail to comply with any of the terms specified herein Second Chance Chi Rescue has the right to reclaim the dog and to enforce this contract in a court of law. In the event that Second Chance Chi Rescue be required to take legal action in order to secure the adopted animal(s), adopter(s) shall pay all costs associated with said legal proceedings. This Contract shall be governed by the laws of the (State of UTAH) without regard to principles of conflict of laws.

THE ABOVE IS A LEGAL AND BINDING CONTRACT. BY SIGNING BELOW, THE ADOPTER(S) AGREES TO COMPLY WITH EVERY CONDITION LISTED ABOVE. THE ADOPTER(S) FURTHER AGREES TO IMMEDIATELY SURRENDER AND RETURN THE ADOPTED PET(S) TO SECOND CHANCE CHI RESCUE SHOULD SECOND CHANCE CHI RESCUE DETERMINE THAT THE ADOPTER(S) HAS FAILED TO COMPLY WITH ANY OF THE CONDITIONS LISTED ABOVE. IN THE EVENT SECOND CHANCE CHI RESCUE BE REQUIRED TO TAKE LEGAL ACTION IN ORDER TO SECURE THE ADOPTED ANIMAL(S), ADOPTER(S) SHALL PAY ALL COSTS ASSOCIATED WITH SAID LEGAL PROCEEDINGS.

I HAVE READ AND UNDERSTAND THIS CONTRACT AND BY SIGNING THIS DOCUMENT I WAIVE ALL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE SECOND CHANCE CHI RESCUE AND ITS OFFICERS, DIRECTORS, AGENTS, EMPLOYEES, VOLUNTEERS AND/OR REPRESENTATIVES.

IN THE EVENT OF MY DEATH OR INCAPACITY, THIS CONTRACT SHALL BE EFFECTIVE AND BINDING UPON MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, AND REPRESENTATIVES.

I have read and understand the Adoption Agreement and understand that my typed name is my legal binding signature and all information provided by me on this application is true and correct to the best of my knowledge: (REQUIRED)

Yes

I hereby grant Second Chance Chi Rescue permission to use my likeness in a photograph/video or any photo/video that I upload to the Second Chance Chi Rescue Facebook page or designated repository (e.g. Flickr) in any and all of its advertising or collateral materials, including the Second Chance Chi Rescue website without payment or any other compensation or consideration. I hereby irrevocably authorize Second Chance Chi Rescue to edit, alter, copy, exhibit, publish or distribute any photos/videos taken of or by me for purposes of publicizing Second Chance Chi Rescue organization or for any other lawful purpose: (REQUIRED)

Yes

As a safety measure for our adopted dogs, we do a home check for anyone wanting to adopt from us. (Do you agree to this home check): (REQUIRED)

Yes

We do a simple background check on everyone wanting to adopt a dog from Second Chance Chi Rescue. We do this to insure the safety of all our dogs after the adoption process. If you select no, you will automatically be denied to adopt from our organization. A criminal background does not disqualify you from adopting from us but helps us make the decision whether or not your the right fit for a Second Chance Chi Rescue dog. (Do You Consent To A Simple Background Check For The Safety Of The Dog(s) You Will Be Adopting): (REQUIRED)

Yes

Signature (Typed Name is a legal binding digital signature): (REQUIRED)

Date Signed (REQUIRED)

Recaptcha Word Verification: