1Page 12Page 23Page 3 Online Application Form If you are registering for a specific dog, please state this on page 3. If you are unsure, we can help guide you in your search for a rescue dog. We recommend being as detailed as possible with your home, lifestyle and the type of dog you are looking for. The data you provide will be used in accordance with the Data Protection Act 2018 and will not be passed to any other organisation. The details will be retained for up to 6 months by Chilterns Dog Rescue Society to help find you a dog and then destroyed if no further contact has been made.Your DetailsName of applicant 1(Required) First Last Name of applicant 2 First Last Contact number 1(Required)Contact number 2Email address(Required) Your HomeAddress(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Upon request, are you able to provide proof of address?(Required)(eg utility bill/driving licence etc) Yes No Type of home(Required) House Flat Other Type of home other(Required)Further details of home(Required) Owned Rented Landlord permission(Required) Yes No Garden size(Required) None Small Medium Large Garden type(Required) Private Communal Boundary None Fence Other Boundary other(Required)Minimum height of boundary(Required)Number of adults in the home(Required)Are there any children under 18 in the home?(Required) Yes No How many children under 18?(Required)Childrens' ages(Required)Are there any visiting children/grandchildren under 18(Required) Yes No How many visiting children/grandchildren under 18(Required)Visiting childrens' ages(Required)Visiting frequency of children(Required) Daily Often Occasionally Do you or any family members have allergies, mobility restrictions or additional requirements which need to be taken into consideration?(Required) Your Home (continued)Do you have any other pets in your home?(Required) Yes No Please state their name(s), breed and neuter statusPet 1(Required)Pet 2Pet 3Pet 4Please tell us more about the animals in your home (include behaviour, temperament, and if they have needed further support)Are there any other animals that will come into regular contact with your new dog?(Required) Yes No Please list details belowAnimal 1(Required)Animal 2Animal 3Animal 4Do you have any previous experience of dogs or dog training? If yes, please state below:Please describe what daily exercise you can offer your new dog (location, distance and duration):(Required)Is there any other additional information that may influence your choice of dog? If yes, please state below:Please list any regular periods of time when the dog would be left at home alone. What arrangements would be put in place to cover your absence?(Required)How soon are you ready to take a dog into your home (please take into consideration any holidays, change of work hours, building work, house moves, medical appointments and other commitments etc)(Required) Details of the dog you are looking forAre you interested in any dogs currently featured on our website and why:Visit our dogs by clicking here.Ideal age from (approx)(Required)Ideal age to (approx)(Required)Type of dog you would preferPedigree (please specify any preferred breeds)CrossbreedSize (you can make multiple choices)(Required) Small - eg Westie Medium - eg Collie Large - eg German Shepherd Gender(Required) Male Female Either Coat (you can make multiple choices)(Required) Short Medium Long Wire coated Activity Level (you can make multiple choices)(Required) High - endless energy/working dog/agility Medium - long walks daily Low - short walks daily Companion - mostly garden exercise Would your new dog need to be a good traveller(Required) Yes No Would you consider a dog from abroad(Required) Yes No Perhaps - to discuss What are the most important qualities in your new dogQuality 1(Required)Quality 2Quality 3Quality 4Are there any dogs you would NOT want to hear about?(Required)Other DetailsName and contact details of your vet (if you have one) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Please add any other relevant information about yourself or your home etcI confirm the above details are true and accurate:Signed(Required)This field is hidden when viewing the formSubmission date DD slash MM slash YYYY CAPTCHA
