Chinchilla Information Questionnaire and Release Form

Please print this form, fill out completely, and have it available when the chinchilla is picked up.

(If surrendering more than one chinchilla, please print one form per chinchilla.)

Chinchilla Information:

I am surrendering the following chinchilla to ForCHINate Chins Chinchilla Rescue:
Name of chinchilla:  _____________________________   Chinchilla color:  ___________
Distinctive markings:  _________________________________________________________
Chinchilla's birthdate (month, day, year):   _________________________ 
If birthdate is unknown, what is the chinchilla's approximate age?   _______
Chinchilla's sex:  Male ___  Female ___  Don't know ___
If this chinchilla is male, is he neutered?  Yes ___  No ___  Don't know ___
If this chinchilla is female, has she had any contact with an unneutered male in the past 4 months? Yes ___  No___  Don't know___

Where did you originally get this chinchilla?          Pet store _____      Breeder _____    
                                                     Rescue/Humane Society _____     Other     _____ 
If from a breeder, who?  ________________________________________________________
If other, where specifically?  _____________________________________________________
What brand of food is the chinchilla currently eating?   ___________________________
What is his/her favorite treat item(s)?   ___________________________________________
What is his/her favorite activity/game(s)? ________________________________________

Has this chinchilla ever been to a veterinarian?:      Yes ___    No  ___ 
If yes, for what reason?   ________________________________________________________
Name of vet clinic/animal hospital:   ____________________________________________
Located in (city):   ______________________________
Vet's phone number (include area code):   _______-_______-__________
Does this chinchilla have any health concerns?  Yes ___   No ___
If yes, please describe:   _________________________________________________________
________________________________________________________________________________

Release of Ownership
I hereby state that I own the chinchilla named on this questionnaire, and release ownership of this chinchilla to ForCHINate Chins Chinchilla Rescue.  I understand that the chinchilla may be made available for adoption through ForCHINate Chins.  The chinchilla will remain with ForCHINate Chins or fostered in another chinchilla rescue until a suitable forever home is found.  I further understand that ForCHINate Chins carefully screens adoption applications, and will reject an application if the applicant does not appear suitable for a chinchilla, ensuring the best possible home for the chinchilla.
Your name:  First________________________      Last_________________________________
Address:   ________________________________________________________
City:  _____________________________,  State:   ________   Zip:  ______________
Phone (including area code):  _______ - _______ - ___________
Email address:  _______________________________   @  ____________________________  .  ________
I would like updates via email about this chin, as long is it is housed with ForCHINate Chins?  Yes ____ No____
Signature:  _____________________________________________  Date:   ___________________
Printed Name:  __________________________________________