tag:blogger.com,1999:blog-70424213541862026852024-03-19T02:10:44.203-07:00CCHSquestionnaireCCHShttp://www.blogger.com/profile/05114123521197266708noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-7042421354186202685.post-72933040879939255862015-10-05T13:29:00.001-07:002015-12-15T15:05:03.568-08:00Adoption procedures include: a pre-adoption questionnaire, an adoption agreement, and an adoption fee. Fees include the animal's vet check, spay/neuter, shots, worming, heartworm testing, feline leukemia testing, and any other medical expense. We do require a personal visit from you to our shelter. We do not transport. Please complete the questionnaire below. You will receive a prompt response; if you do not, please email us directly at clintoncohumanesociety@yahoo.com.<!-- Begin Response-O-Matic Form -->
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<form enctype="multipart/form-data" method="post" action="http://www.response-o-matic.com/mail.php" accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="019dvxaeqzqxqbv6" />
<input type="hidden" name="formid" id="formid" value="471654" />
<input type="hidden" name="required_vars" id="required_vars" value="name,field-e0c7e5d8a289b19,field-26bdf7244678815,field-8febcb0f2dde985,field-c8d5e2f9d4d901d,field-e43d8735d097994,field-404a9cf2a7422c8,field-9e61807b19db6a4,email,field-eb0c292b052c506,field-09c57e41b57842a,field-7186bf22f2e57c2,field-63734a2bc22932f,field-76e13823424d5c0,field-2ccded0d2303ac9,field-7d04ede29fc9ce6,field-dbb2f152dcda85f,field-17b048f3702eb82,field-77deac376e5a182,field-060aa05bbd835f0,field-293b3aa9cf82cae,field-4c9991fadc36451,field-c14f9317bdb8a70,field-8d4ad5e3cef3562,field-1dee88971aa64c9,field-68834fcb54508d0,field-94bb113e693a5d8,field-a6324d97b917661,field-073ec502903232d,field-14dc38882fb2cc2,field-25bfaf027532f92,field-21ab824321dcd30,field-de378b3ecc30b6a,field-1a12edc9c472545,field-e69178f025e908e" />
</div>
<table cellspacing="5" cellpadding="5" border="0">
<tr>
<td valign="top">
<strong>Animal Name:</strong>
</td>
<td valign="top">
<input type="text" name="name" id="name" size="40" value="" />
</td>
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<tr>
<td valign="top">
<strong>Your full name:</strong>
</td>
<td valign="top">
<input type="text" name="field-e0c7e5d8a289b19" id="field-e0c7e5d8a289b19" size="40" value="" />
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<td valign="top">
<strong>Age of adopter:</strong>
</td>
<td valign="top">
<input type="text" name="field-26bdf7244678815" id="field-26bdf7244678815" size="40" value="" />
</td>
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<td valign="top">
<strong>Street address:</strong>
</td>
<td valign="top">
<input type="text" name="field-8febcb0f2dde985" id="field-8febcb0f2dde985" size="40" value="" />
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<strong>City:</strong>
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<input type="text" name="field-c8d5e2f9d4d901d" id="field-c8d5e2f9d4d901d" size="40" value="" />
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<td valign="top">
<strong>State:</strong>
</td>
<td valign="top">
<input type="text" name="field-e43d8735d097994" id="field-e43d8735d097994" size="40" value="" />
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<strong>ZIP:</strong>
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<td valign="top">
<input type="text" name="field-404a9cf2a7422c8" id="field-404a9cf2a7422c8" size="40" value="" />
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<strong>Primary phone:</strong>
</td>
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<input type="text" name="field-9e61807b19db6a4" id="field-9e61807b19db6a4" size="40" value="" />
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<strong>Email address:</strong>
</td>
<td valign="top">
<input type="text" name="email" id="email" size="40" value="" />
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<tr>
<td valign="top">
<strong>Do you rent or own?</strong>
</td>
<td valign="top">
<select name="field-eb0c292b052c506" id="field-eb0c292b052c506">
<option value=""></option>
<option value="Rent">Rent</option>
<option value="Own">Own</option>
</select>
</td>
</tr>
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<td valign="top">
<strong>How long have you lived at this address?</strong>
</td>
<td valign="top">
<input type="text" name="field-09c57e41b57842a" id="field-09c57e41b57842a" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>If you rent, does your lease allow pets?</strong>
</td>
<td valign="top">
<select name="field-7186bf22f2e57c2" id="field-7186bf22f2e57c2">
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="Not applicable">Not applicable</option>
</select>
</td>
</tr>
<tr>
<td valign="top">
<strong>How many pets are allowed on lease?</strong>
</td>
<td valign="top">
<input type="text" name="field-63734a2bc22932f" id="field-63734a2bc22932f" size="40" value="" />
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<td valign="top">
<strong>Do you live in a house, condo, apartment, mobile home?</strong>
</td>
<td valign="top">
<input type="text" name="field-76e13823424d5c0" id="field-76e13823424d5c0" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Is your yard fenced, and what is the approximate size?</strong>
</td>
<td valign="top">
<input type="text" name="field-2ccded0d2303ac9" id="field-2ccded0d2303ac9" size="40" value="" />
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</tr>
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<td valign="top">
<strong>Do you currently own other pets?</strong>
</td>
<td valign="top">
<select name="field-7d04ede29fc9ce6" id="field-7d04ede29fc9ce6">
<option value=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</td>
</tr>
<tr>
<td valign="top">
<strong>Please list breed, gender, and age of current pets:</strong>
</td>
<td valign="top">
<textarea name="field-dbb2f152dcda85f" id="field-dbb2f152dcda85f" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Have you previously owned pets? </strong>
</td>
<td valign="top">
<select name="field-17b048f3702eb82" id="field-17b048f3702eb82">
<option value=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</td>
</tr>
<tr>
<td valign="top">
<strong>What breed/types have you owned in the past?</strong>
</td>
<td valign="top">
<textarea name="field-77deac376e5a182" id="field-77deac376e5a182" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>How long did you have the pet(s), and where are they now?</strong>
</td>
<td valign="top">
<textarea name="field-060aa05bbd835f0" id="field-060aa05bbd835f0" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Are your pets spayed and/or neutered? If not, why not?</strong>
</td>
<td valign="top">
<textarea name="field-293b3aa9cf82cae" id="field-293b3aa9cf82cae" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Are your current dogs licensed? If not, why not?</strong>
</td>
<td valign="top">
<textarea name="field-4c9991fadc36451" id="field-4c9991fadc36451" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Are your pets current on vaccinations? If not, why not?</strong>
</td>
<td valign="top">
<textarea name="field-c14f9317bdb8a70" id="field-c14f9317bdb8a70" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Have you ever taken a pet to the pound? If yes, please explain.</strong>
</td>
<td valign="top">
<textarea name="field-8d4ad5e3cef3562" id="field-8d4ad5e3cef3562" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>If you have children in your household what are their ages and relationship to you.</strong>
</td>
<td valign="top">
<textarea name="field-1dee88971aa64c9" id="field-1dee88971aa64c9" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Is anyone in your household allergic to animals? If so, whom and to what type of pet?</strong>
</td>
<td valign="top">
<textarea name="field-68834fcb54508d0" id="field-68834fcb54508d0" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Why are you interested in this pet?</strong>
</td>
<td valign="top">
<textarea name="field-94bb113e693a5d8" id="field-94bb113e693a5d8" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Is this pet a gift for someone? If so, whom?</strong>
</td>
<td valign="top">
<textarea name="field-a6324d97b917661" id="field-a6324d97b917661" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>What is your preferred level of exercise for a dog?</strong>
</td>
<td valign="top">
<input type="radio" name="field-073ec502903232d" id="field-073ec502903232d_0" value="Couch potato" /> Couch potato<br/>
<input type="radio" name="field-073ec502903232d" id="field-073ec502903232d_1" value="Yard exercise" /> Yard exercise<br/>
<input type="radio" name="field-073ec502903232d" id="field-073ec502903232d_2" value="Short walks" /> Short walks<br/>
<input type="radio" name="field-073ec502903232d" id="field-073ec502903232d_3" value="Vigorous walks" /> Vigorous walks<br/>
<input type="radio" name="field-073ec502903232d" id="field-073ec502903232d_4" value="Hiking/jogging" /> Hiking/jogging<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Where will the animal be kept?</strong>
</td>
<td valign="top">
<input type="text" name="field-14dc38882fb2cc2" id="field-14dc38882fb2cc2" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>When inside, how do you plan to keep your pet? Check all that apply.</strong>
</td>
<td valign="top">
<input type="radio" name="field-25bfaf027532f92" id="field-25bfaf027532f92_0" value="Free inside house" /> Free inside house<br/>
<input type="radio" name="field-25bfaf027532f92" id="field-25bfaf027532f92_1" value="Confined to a crate" /> Confined to a crate<br/>
<input type="radio" name="field-25bfaf027532f92" id="field-25bfaf027532f92_2" value="Inside a closed room" /> Inside a closed room<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>When outside, how do you plan to keep your pet? Check all that apply.</strong>
</td>
<td valign="top">
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_0" value="Not applicable; indoors only" /> Not applicable; indoors only<br/>
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_1" value="Tie-out chain" /> Tie-out chain<br/>
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_2" value="Garage" /> Garage<br/>
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_3" value="Patio area" /> Patio area<br/>
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_4" value="Invisible fence" /> Invisible fence<br/>
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_5" value="Fenced yard" /> Fenced yard<br/>
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_6" value="Outside dog run" /> Outside dog run<br/>
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_7" value="Leash and regular walks" /> Leash and regular walks<br/>
<input type="radio" name="field-21ab824321dcd30" id="field-21ab824321dcd30_8" value="Loose in yard, unattended" /> Loose in yard, unattended<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Who will be responsible for medical and/or training costs?</strong>
</td>
<td valign="top">
<input type="text" name="field-de378b3ecc30b6a" id="field-de378b3ecc30b6a" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Current or past veterinary facility and its phone number:</strong>
</td>
<td valign="top">
<input type="text" name="field-1a12edc9c472545" id="field-1a12edc9c472545" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Where did you first learn of this website?</strong>
</td>
<td valign="top">
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_0" value="Advertisement" /> Advertisement<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_1" value="Petfinder.com" /> Petfinder.com<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_2" value="Another website" /> Another website<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_3" value="Search engine" /> Search engine<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_4" value="Newspaper" /> Newspaper<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_5" value="Suggestion from Friend" /> Suggestion from Friend<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_6" value="Facebook" /> Facebook<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_7" value="Instagram" /> Instagram<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_8" value="Twitter" /> Twitter<br/>
<input type="radio" name="field-e69178f025e908e" id="field-e69178f025e908e_9" value="Other" /> Other<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Comments or Questions?</strong>
</td>
<td valign="top">
<textarea name="field-df446056718d01e" id="field-df446056718d01e" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
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CCHShttp://www.blogger.com/profile/05114123521197266708noreply@blogger.com0