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 for each chinchilla.)

Chinchilla Information

I am surrendering the following chinchilla to Second Chance 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 been in 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:   ______-______-________

Does this chinchilla have any current health concerns?  Yes _____   No _____

If yes, please describe:   _______________________________________________________________________

___________________________________________________________________________________________________

Chinchilla's medical history:
(include birth of kits, infections, injuries, dental problems, etc.  Please provide the dates and any medications used for treatment.  Use the back of this form if you need more room.)

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Release of Ownership

I hereby state that I own the chinchilla named on this questionnaire, and release ownership of this chinchilla to Second Chance Chins Chinchilla Rescue.  The chinchilla will remain with Second Chance Chins until a suitable forever home is found or may be transferred to another qualified chinchilla rescue for rehoming.  I understand that the chinchilla will be made available for adoption.  I further understand that Second Chance 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.  All supplies donated with the surrender of this chinchilla are now property of Second Chance Chins to be used for the rescue, donated to another rescue or sold and funds used to further the efforts of the rescue.

Your name:  First________________________      Last_________________________________

Address:   ________________________________________________________

City:  _____________________________,  State:   ________   Zip:  ______________

Phone (including area code):  _______ - _______ - ___________

Email address:  ____________________________  @  ________________________  .  ________