Step 1 of 10 0% Thank you for your interest in adopting a dog rescued by A New Chance Animal Rescue. We want to make sure that every dog that we place goes to a loving and appropriate home where they will be well cared for. Because of this, we require all applicants to complete a number of detailed questions necessary for our screening process.This application must be completed in full in order to be processed. Please allow at least 30 minutes to ensure that it is complete. All information will be kept confidential.Please note: We do not currently adopt dogs beyond a 90-mile radius of Bedford Hills, New York. If you are uncertain if you qualify, please go to Google Maps to verify that you are eligible to adopt BEFORE you complete this application. Before filling out your adoption application, you must acknowledge each of the following:* I live within a 90-mile radius of Bedford Hills, New York. * I am willing and able to pay for vet care for my adopted dog which can cost over $1,250 a year. * I understand that there is an adoption donation of $500 and agree to pay that donation. I understand that this donation amount, in most cases, only covers part of the expenses associated with my adoption and that A New Chance Animal Rescue must subsidize the added expense through fundraising. * Depending upon the particular animal, dogs can live to be as old as 17 years of age. I understand this and am committed to caring for my adopted dog for the length of his/her life. * I understand that some dogs require a period of weeks or even months to adjust to their new home/environment/family/other pets and may need training sessions to resolve behavioral and adjustment issues. * I verify that everyone living in my home is in agreement to adopt a dog at this time. * I am 21 years of age or older. Proof of age will be required prior to completing adoption. * I understand that the information in my application to A New Chance Animal Rescue is confidential. * Upon adoption, I give permission to A New Chance Animal Rescue to use my email address to send me occasional updates or news. I understand that A New Chance Animal Rescue will not reveal or sell any of my contact information to a third party. * I understand that A New Chance Animal Rescue has the right to decline my application. * I understand that A New Chance Animal Rescue is entirely run by volunteers who will do their best to see that my application is processed as rapidly as possible. * I understand that if any of the information on this application is misrepresented or is found to be in the future, my application will be automatically declined. If I have already adopted the dog, the dog will be reclaimed. * I understand that A New Chance Animal Rescue has the right to inspect my premises for any reason to verify the accuracy of this application. * I verify that everyone who lives in my household is in agreement to visit the foster home prior to adoption. * I have read the description of the dog(s) I am submitting this application for and understand that if my application is not appropriate for the dog(s) based on the criteria in the description, ANCAR’s volunteers will not be able to process it. * I am ready to adopt within 5 to 10 days of filing this application. If not, please do not apply until that time. What dog(s) are you interested in adopting?First ChoiceSelect a DogKodiakKaiKikiKingstonAnastasiaSushiJackOliverFudgeZuzuCallieShadowSunflowerHenrySashimiHarryHopeEllie * Adoption Pending *MimiBreeBarkleyNovaSapphireCasperJanet * Adoption Pending *CassieShepRhodaAlizRain * Adoption Pending *Harley * Adoption Pending *Hunter * Adoption Pending *KonaMilly * Adoption Pending *HollyAmber * Adoption Pending *TessieBirdiBearBoltMollyGoldieEmilyPolarRileyWallaceMcKynleeSecond ChoiceSelect a DogKodiakKaiKikiKingstonAnastasiaSushiJackOliverFudgeZuzuCallieShadowSunflowerHenrySashimiHarryHopeEllie * Adoption Pending *MimiBreeBarkleyNovaSapphireCasperJanet * Adoption Pending *CassieShepRhodaAlizRain * Adoption Pending *Harley * Adoption Pending *Hunter * Adoption Pending *KonaMilly * Adoption Pending *HollyAmber * Adoption Pending *TessieBirdiBearBoltMollyGoldieEmilyPolarRileyWallaceMcKynleeThird ChoiceSelect a DogKodiakKaiKikiKingstonAnastasiaSushiJackOliverFudgeZuzuCallieShadowSunflowerHenrySashimiHarryHopeEllie * Adoption Pending *MimiBreeBarkleyNovaSapphireCasperJanet * Adoption Pending *CassieShepRhodaAlizRain * Adoption Pending *Harley * Adoption Pending *Hunter * Adoption Pending *KonaMilly * Adoption Pending *HollyAmber * Adoption Pending *TessieBirdiBearBoltMollyGoldieEmilyPolarRileyWallaceMcKynlee Applicant Contact InformationName:* First Last Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email:* Home Phone (include area code):*Cell Phone (include area code):* Your HouseholdHow many adults live in your household?*1234More than 4Adult 1Name:* Age:* Are you employed?*Please select oneYesNoRetiredStudentOccupation:* Employer:* Employer address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work phone (include area code):*Work hours:* Time you leave for work:* Time you return from work:* I attend:* Full-time Part-time In what state do you attend school?* When do you graduate?* How many hours a week do you devote to school (include class time, studying, commute, school activities)?* Adult 2Adult 2 name:* Adult 2 age:* Adult 2 relationship to applicant:*Please select oneSpouse/PartnerChildParentSiblingRoommateOtherIs Adult 2 employed?*Please select oneYesNoRetiredStudentAdult 2 occupation:* Adult 2 employer name:* Adult 2 employer address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Adult 2 work phone (include area code):*Adult 2 work hours:* Time Adult 2 leaves for work* Time Adult 2 returns from work:* Adult 2 attends:* Full-time Part-time In what state does Adult 2 attend school?* When does Adult 2 graduate?* How many hours does Adult 2 devote to school (include class time, studying, commute, student activities)?* Adult 3Adult 3 name:* Adult 3 age:* Adult 3 relationship to applicant:*Please select oneSpouse/PartnerChildParentSiblingRoommateOtherIs Adult 3 employed?*Please select oneYesNoRetiredStudentAdult 3 occupation?* Adult 3 employer:* Adult 3 employer address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Adult 3 work hours:* Adult 3 work phone (include area code):*Time Adult 3 leaves for work:* Time Adult 3 returns from work:* Adult 3 attends school:* Full-time Part-time In what state does Adult 3 attend school?* When does Adult 3 graduate?* How many hours a week does Adult 3 devote to school (include class time, studying, commute, student activities)?* Adult 4Adult 4 name:* Adult 4 age:* Adult 4 relationship to the applicant:*Please select oneSpouse/PartnerChildParentSiblingRoommateOtherIs Adult 4 employed?*Please select oneYesNoRetiredStudentAdult 4 occupation:* Adult 4 employer:* Adult 4 employer address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Adult 4 work phone (include area code):*Adult 4 work hours:* Time Adult 4 leaves for work:* TIme Adult 4 returns from work:* Adult 4 attends school:* Full-time Part-time In what state does Adult 4 attend school?* When does Adult 4 graduate?* How many hours a week does Adult 4 devote to school (include class time, studying, commute, school activities)?* More than Four Adults in HouseholdPlease list additional adults not mentioned above:How many children live in your household?*Please select one0123456Age of first child:* Gender of first child:*Please select oneFemaleMaleAge of second child:* Gender of second child:*Please select oneFemaleMaleAge of third child:* Gender of third child:*Please select oneFemaleMaleAge of fourth child:* Gender of fourth child:*Please select oneFemaleMaleAge of fifth child:* Gender of fifth child:*Please select oneFemaleMaleAge of sixth child:* Gender of sixth child:*Please select oneFemaleMaleDo any children regularly visit your household?*Please select oneYesNoIf yes, please describe ages of children and visit frequency.*Do you regularly take care of any dogs that you do not own?*Please select oneYesNoIf yes, please explain frequency of care and include dog type, age, gender, personality, and size of each dog you regularly care for:*Are all members of your household in agreement about adopting a dog?*Please select oneYesNoNot sureI want it to be a surpriseIs anyone in your household nervous or unsure around dogs?*Please select oneYes, very fearfulYes, moderately fearfulYes, a tad fearfulNoIf yes, please explain:*For whom would you be adopting the dog?*Please select oneMyself/My FamilyMy Child/ChildrenSomeone ElseWho will be the primary caregiver for this dog?* Who will be financially responsible for this dog?* Are all members of your household willing and able to come to the foster home to meet the dog in which you are interested?*Please select oneYesNoNot sureIf no, please explain:*Do any members of your household have asthma or are allergic to dogs?*Please choose oneYesNoNot sureIf yes, who?* Please explain the severity of their dog allergy:* Are they taking medications for their allergy?* Please describe your household activity/noise level:*Please select oneHigh – A lot of noise and activityMedium – Moderate amount of noise and activityLow – Quiet and calmHow often does the primary caregiver travel away from home?*Please select oneFrequently (10+ times a year)Occasionally (5 to 10 times a year)Rarely (1 to 4 times a year)NeverHow many hours would your dog be alone during the day? (Please consider the time you leave for work, what time you return home, errands, after-school activities, etc.)*Are any household trips planned in the next 6 months?*Please select oneYesNoNot sureIf yes, how many trips are planned and for how long?*How will you care for your dog when you are away from home? Who will provide the care?*In the event of a short-term (up to one week) emergency, who would care for your dog and what arrangements would be made?*In the event of a long-term (up to 3 months) emergency, who would care for your dog and what arrangements would be made?*In the event of the death of the primary caretaker, who would care for your dog and what arrangements would be made?* Your ResidencePlease describe your type of residence:* House Condo/Co-Op Apartment Mobile Home Dormitory Other Do you own or rent?* Own Rent Live at home Live with relatives Landlord's name:* Landlord's phone (include area code):*Landlord's phone (include area code):*Landlord's email Does your landlord, building, co-op, or condo association allow dogs?*Please choose oneYesYes, with restrictionsNot sureNoPlease provide us with the contact information for your co-op or condo association.*Please explain pet ownership restrictions:*How long have you lived at this address?* How many times have you moved in the last 5 years?* Do you have any plans to move in the next few years?*Please select oneYesNoNot sureIf yes, please explain your plans to move:*What would you do if you moved to a residence where dogs were not permitted?*Please describe your home's setting:* City Town Suburban Suburban/Rural Rural Do you live on a busy road?*Please select oneYesNoDo you have a fenced-in yard?*Please select oneYesNoIs it fully enclosed?*Please select oneYesNoPlease describe your fence type:* Chainlink Wooden Metal Invisible Other If other, please describe your fence:*How high is your fence?* Is your fence the same height all around?*Please select oneYesNoNot sureIf no, please describe your fence configuration:*Approximately how big is your fenced in yard (sq. ft.)?* If you do not have a fence, do you plan to install one?*Please select oneYesNoNot sureWhen do you plan on installing a fence and what kind?*Do you have a runner or chain for a dog that you plan to use?*Please select oneYesNoIf yes, please explain:* Your Current PetsDo you currently own any other animals (excluding fish)?*Please select oneYesNoPlease indicate the type of animal you have (check all that apply):* Dog Cat Bird Small mammal Reptile and/or amphibian Chicken Sheep Horse Other Currently owning one or more dogsHow many dogs do you currently own?*Please select one123 or moreFirst DogName of dog one:* Breed of dog one:* Size of dog one (lbs.):* Age of dog one:* Gender of dog one:*Please select oneMaleFemaleIs dog one spayed or neutered?*Please select oneYesNoIf dog one is not spayed or neutered, please explain:*How long have you owned dog one?* Please describe the personality of dog one:*Does dog one get along with other dogs?*Please select oneYesNoNot sureIf no or not sure, please explain (dog one):*Are you experiencing any difficulties with dog one in terms of health or behavior?*Please select oneYesNoIf yes, please explain:*Second DogName of dog two:* Breed of dog two:* Size of dog two (lbs.):* Age of dog two:* Gender of dog two:*Please select oneMaleFemaleIs dog two spayed or neutered?*Please select oneYesNoIf dog two is not spayed or neutered, please explain:*How long have you owned dog two?* Please describe the personality of dog two:*Does dog two get along with other dogs?*Please select oneYesNoNot sureIf no or not sure, please explain (dog two):*Are you experiencing any difficulties with dog two in terms of health or behavior?*Please select oneYesNoIf yes, please explain (dog two):*Third DogName of dog three:* Breed of dog three:* Size of dog three (lbs.):* Age of dog three:* Gender of dog three:*Please select oneMaleFemaleIs dog three spayed or neutered?:Please select oneYesNoIf dog three is not spayed or neutered, please explain:*How long have you owned dog three?* Please describe the personality of dog three:*Does dog three get along with other dogs?*Please select oneYesNoNot sureIf no or not sure, please explain:*Are you experiencing any difficulties with dog three in terms of health or behavior?*Please select oneYesNoIf yes, please explain:*Do you own more than 3 dogs?*Please select oneYesNoIf yes, name and describe each of your additional dogs:*Canine Veterinary CareCanine veterinarian name:* Canine veterinary practice:* Canine veterinary address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Canine veterinary phone (include area code):*Do you use the same canine vet for sick care and routine care (vaccinations, annual checkup)?*Please select oneYesNoIf no, please provide the canine vet's name, the services they provide and a phone number:*Do you use any other canine vets or vet specialists?*Please select oneYesNoIf yes, please provide vet's name, services they provide and a telephone number:*Have you used another canine vet within the last 5 years?*Please select oneYesNoIf yes, please provide the vet's name and phone number:*Is your dog currently vaccinated for rabies?*Please select oneYesNoNot sureDo you use heartworm preventative on your dog(s)?*Please select oneYesNoNot sureWhat kind of heartworm preventative?* How often do you give heartworm preventative?* Do you use flea and tick preventative on your dog(s)?*Please select oneYesNoNot sureWhat kind of flea and tick preventative do you use?* How often do you apply flea and tick preventative on your dog(s)?* Currently Owning One or More CatsHow many cats do you own?*Please select one123More than 3First CatName of cat one:* Age of cat one:* Gender of cat one:*Please select oneMaleFemalePlease description cat one's personality:*Does cat one get along with dogs?Please select oneYesNoNot sureIf no or not sure, please explain (cat one):*Second CatName of cat two:* Age of cat two:* Gender of cat two:*Please select oneMaleFemalePlease describe cat two's personality:*Does cat two get along with dogs?*Please select oneYesNoNot sureIf no or not sure, please explain:*Third CatName of cat three:* Age of cat three:* Gender of cat three:*Please select oneMaleFemalePlease describe the personality of cat three:*Does cat three get along with dogs?*Please select oneYesNoNot sureIf no or not sure, please explain:*More than three catsPlease describe the additional cats you own in the space provided:*Feline Veterinary CareFeline veterinary name:* Feline veterinary practice:* Feline vet address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Feline vet phone (include area code):*Currently owning one or more birdsHow many birds do you own?* What type of bird(s) do you own?* Please describe the living arrangements for your bird(s):*Currently owning reptile(s) and/or amphibian(s)How many reptiles and/or amphibians do you own?* What type of reptile(s) and/or amphibian(s) do you own?* Please describe the living arrangements of your reptile(s) and/or amphibian(s):Currenly owning small mammal(s)How many small mammals (guinea pigs, mice, ferrets, etc) do you own?* What type of small mammal(s) do you own?* Please describe the living arrangements of your small mammals:*Currently owning horse(s), sheep, and/or chicken(s)How many horse, sheep, and/or chicken do you own?* Please describe their living arrangements:*Equine Veterinary CareEquine veterinary name:* Equine veterinary practice:* Equine vet office:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Equine vet phone (include area code):*Currently owning other types of animalsPlease describe the other types of pets that you own and their living arrangements:* Previous Dog Ownership and ExperienceHas every member of your household been around dogs at some point in their life?*Please select oneYesNoNot sureIf no or not sure, please explain:*Have you had the experience of being a primary caregiver to a dog?*Please select oneYes, I have been the primary caregiver and owner of one or more dogs previouslyYes I have experienced being the primary caregiver to a dog, but I did not own the dog.NoPlease describe the care and the length of care the you provided:*Have you ever given a dog away, given it to a shelter or rescue group, returned it a breeder, given it to a friend or sold it?*Please select oneYesNoIf yes, please explain:*Have you ever had a dog for a short period of time and it did not work out?*Please select oneYesNoIf yes, please explain:*Have you ever had your dog lost or stolen?*Please select oneYesNoIf yes, please explain:*Have you ever had to retrieve your dog from a pound, shelter or animal control facility?*Please select oneYesNoIf yes, please explain:*Have you ever had your dog die as the result of being hit by a car, being poisoned or from unknown causes?*Please select oneYesNoIf yes, please explain:*Have you had a dog that gave birth?*Please select oneYesNoIf yes, please explain:*Have you ever adopted from A New Chance?*Please select oneYesNoHave you previously applied to adopt from A New Chance?*Please select oneYesNoHave you ever been denied a dog adoption?*Please select oneYesNoWho denied your dog adoption (check all that apply)* A New Chance Animal Rescue An animal shelter Other rescue groups Please explain the reason for their denial:*Dog Ownership HistoryExcluding the dogs you currently own, how many other dogs have you owned over the past 10 years?*Please select oneNone1234More than 4Dog OneName of dog one:* Species/breed of dog one:* Was dog one spayed or neutered?*Please select oneYesNoAge of dog one during ownership:* What happened to dog one?*If dog one died, at what age? In what year did he/she die?* Vet used for dog one:* First Last Vet phone for dog one (include area code):*Dog TwoName of dog two:* Species/breed:* Was dog two spayed or neutered?*Please select oneYesNoAge of dog two during ownership:* What happened to dog two?*If dog two died, at what age? In what year did he/she die?* Vet used for dog two:* First Last Vet phone for dog two (include area code):*Dog ThreeName of dog three* Species/breed of dog three:* Was dog three spayed/neutered?*Please select oneYesNoAge of dog three during ownership:* What happened to dog three?*If dog three died, at what age? In what year did he/she die?* Vet used for dog three:* First Last Vet phone for dog three (include area code):*Dog FourName of dog four:* Species/breed of dog four:* Was dog four spayed/neutered?*Please select oneYesNoAge of dog four during ownership:* What happened to dog four?*If dog four died, at what age? In what year did he/she die?* Vet used for dog four:* First Last Vet phone for dog four (include area code):*Four or more dogs owned over the last 10 yearsPlease provide names, species, ownership dates and vet used for each additional dog you have owned:* Care for your New DogWhere will your new dog live?* Indoors mostly/outdoors for exercise and elimination Outdoors mostly/indoors on occasion Outdoors only Not sure Where will the new dog be allowed to be indoors?* Confined to a specific room or rooms Free roam inside In a crate In which rooms will the dog be allowed?*Where will the dog live outside?*Please select oneFenced-in yardFree roam outdoorsFenced-in area (not yard)Please explain:*Is there shelter outside for the dog?*Please select oneYesNoPlease explain the shelter type*Where will your new dog be kept when you are out (check all that could apply)?* Confined to a specific room or rooms In crate Free roam inside Free roam outside Fenced-in yard or area Dog house/shelter outside Garage Basement Where will your new dog be kept at night (check all that could apply)?* Confined to a specific room or rooms In crate Free roam inside Fenced-in yard or area Free roam outside In a dog house/shelter outside Garage Basement What veterinary practice do you plan to use?* Veterinary address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Veterinary phone (include area code):*If you adopt a dog who has not been spayed or neutered, do you intend to spay or neuter the dog?*Please select oneYes, I will spay or neuter the dog.No, I plan to breed the dog.No, my dog will always be monitored.Not sureAre you aware that some dogs require a period of weeks or even months to adjust to their new home/environment/family/other pets?*Please select oneYesNoAre you willing to allow for this adjustment period?*Please select oneYesNo, I prefer a pet who will adjust quicklyNot sureAre you willing and able to bring your new dog to a vet for yearly exams and vaccinations?*Please select oneYesNoNot sureAre you willing and able to bring your new dog to a vet for annual heartworm tests?*Please select oneYesNoNot sureAre you willing and able to give heartworm preventative according to product directions?*Please select oneYesNoNot sureAre you willing and able to give flea and tick preventative to your new dog according to product directions?*Please select oneYesNoNot sureAre you able and willing to pay for emergency care for your new dog, which could result in a bill of $200 to $1,000 or more?*Please select oneYesNoNot sureAre you able and willing to pay for pet expenses, including veterinary care, supplies, toys, boarding/pet sitting, grooming, food, etc.?*Please select oneYesNoNot sureAre you able to commit to providing a home for a dog for the life of the dog?*Please select oneYesNoNot sureWhat circumstances might justify giving up a dog? (check all that apply)* New baby Moving Divorce Shedding Allergies Dog aggression Excessive chewing Separation anxiety Want to travel Behavior problems Dog becomes ill Children lost interest Dog not getting along with other pets Cannot afford Destructive New household member dislikes dog House soiling/urine marking Too time consuming None Other If your new dog exhibits behavioral or adjustment issues, would you be willing to seek the advice of A New Chance representative?*Please select oneYesNoNot sureWould you be willing to pay for obedience or behavioral sessions?*Please select oneYesNoNot sure My New Dog Wish ListI prefer a dog that is:* Extra-small (under 10 lbs.) Small (11 to 25 lbs.) Medium (26 to 45 lbs.) Medium/large (46 to 70 lbs.) Large (71 to 95 lbs.) Extra-large (96 lbs +) Any size I want to adopt a dog for (check all that apply):* Companionship Watch dog House pet Breeding Travel companion Company for a family member A gift for a friend or a relative Hunting Agility sports Herding Dog energy level I prefer:* High Medium Low What types of activities do you want to do with your new dog?*I prefer a dog who is (check all that apply):* Puppy (up to 6 months) Young adult (6 to 12 months) Adult (1+ year) Senior (7+ years) Male Female Indoor only Indoor/outdoor Mainly an outdoor dog Very active/energetic Mellow/quiet Hypoallergenic Lap dog Protective Friendly Likely to be housetrained Spayed/Neutured Breeds or mixes of dogs that I prefer:*Why do you prefer this breed(s) or mix(es)?*Please describe how you relate to dogs:*Please select oneStrict, demanding and a strong leaderLenient, a little wishy washy and easily coerced by a dogSomewhere in betweenMy ideal dog would:*Bad dog habits I cannot tolerate:*Please share with us anything you would like for us to know about the new dog that you would like to add to your family:Would you be interested in learning about some of our "special needs" or "long-term resident" dogs?*Please select oneYesNoNot sureWould you be willing to have an in-house visit by A New Chance representative before you adopt from us?*Please select oneYesNoNot sureWould you be willing to have an in-house visit by A New Chance representative after you have adopted from us?*Please select oneYesNoNot sureOnce your new adopted dog is settled in, would you be interested in learning more about fostering a rescue dog?*Please select oneYesNoNot sure My ReferencesPlease provide three personal references who are NOT related to you.Name* Relationship to you* Home Phone (include area code)Cell Phone (include area code)*Name* Relationship to you* Home Phone (include area code)Cell Phone (include area code)*Name* Relationship to you* Home Phone (include area code)Cell Phone (include area code)*Additional information you would like us to know: