A Chance for Champ Adoption Application



Phone (H):                                           (W):                                                   

Email Address:                                                                                                                                   


City:                                                                 State:              Zip Code:                                           

  1. Do you Rent or Own You home?                                                                                           

  2. If you rent, do you have express permission from your landlord to add a new dog to your home?

  3. How long have you lived at your current address?                                                               

  4. Do you have children? If so, how many and what ages?

  5. Have you owned a dog before?(Please circle) Yes/No

  6. If yes to above, please List: (Breed, Age, Gender)





*A Vet Reference is required if you own any other animals.

  1. What is the name and number for the veterinarian that you currently use for your pets?

  2. Are your pets current on Rabies and yearly vaccinations?                                                   

  3. Do you currently give any heartworm prevention to your pets? If yes, what brand?

  4. Where will your new dog be during the day? Please be very specific:

  5. Where will the dog stay during the night? Please be very specific:

  6. Will your new dog be and inside or outside dog?                                                                 

  7. Will someone be home with the dog during the day? If yes, for how long during the day?

  8. How many hours will this dog be alone during the day?                                                      

  9. If you adopt a young puppy, they will unable to hold their urine for longer than a few hours at a time. To make housebreaking a success, someone will need to let the new puppy out to potty every few hours. If you are working, will you have someone that can stop by your house and walk your puppy?                                                                                   

  10. Will you adopt a dog/puppy who needs to be housebroken?                                              

  11. Will you adopt a dog who needs obedience training?                                                          

  12. Do you have a fenced in yard? Please circle one: Yes/No

  13. If yes, what type of fence is it, and how high is it?                                                                

  14. If your yard is not fenced, please describe how you plan to confine your dog to your property:

  15. Do you have an exercise plan for your dog? If so please describe:

  16. Are you willing to obtain a crate and crate train your new dog?                                          

  17. Are you willing to take our dog to a basic obedience course? If not please explain why:

  18. What behaviors would cause you to give up your dog?

  19. Do you understand that you will need to purchase monthly heartworm prevention, and you will spend hundreds of dollars on your dog each year? This cost will include vet care, food, licensing, training, toy, treats, etc?                                                                               

  20. What gender dog do you prefer? Please circle one: Male/Female/No preference

  21. What age range are you looking to adopt?

    • 3-6 months

    • 6-12 months

    • 1-2 years

    • 2-4 years

    • 4-6 years

    • Senior (7+)

    • No preference

  22. Would you consider adopting a mixed breed? Please circle one: Yes/No

  23. Is there a specific dog you are interested in who is currently in our rescue? If so, please give us the animal’s name:                                                                                                          

  24. Will you allow one of our staff to come to your home and do a home visit prior to adoption? Please circle one: Yes/No

All dogs who are adopted through A Chance for Champ must be spayed or neutered. There are NO Exceptions.

I acknowledge that all the information on this form is true and correct. I understand that any misrepresentation of fact may result in the removal of the adopted dog from my home.

Signature:                                                                                            Date:                                      

Co-Applicant Signature:                                                                      Date:                                     

PO Box 76

Seymour, TN 37865

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