First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

County

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

Is this animal owned by you?

If this is an animal you own is it being given up because you are moving? If so please describe the circumstances and why the pet can not move with you.

If this is an owned animal you can no longer keep due to moving please give us the date you will be moving.

Are you having to give up your personal pet (s) due to financial hardship?

If some of the pet(s) food/care expenses could be provided for you would you be willing to keep your pet(s)?

If you are not moving or having any financial hardships why are you no longer able to keep your pet(s)? (Please be specific and if this is a stray animal put N/A)

How did you acquire the pet(s)/stray(s) that need a new home?

If the pet(s) were adopted from what organization did you adopt them from and when?

If the pet(s) were a gift what was the occasion?

Is this a stray(s) you picked up?

If the animal(s) were a stray(s) you took in what was the date you found them?

If the animal(s) were stray(s) you took in what street and zip code were they found in?

Please complete the questions below for each animal(s) you need to have placed in a new home. If you have picked up 2 or more stray dogs then use a coma and enter the information for each one of them. If strays with no name just put Stray 1, Stray 2 etc. You may also enter any additional information you would like us to know below:

What is the pet(s)/stray(s) name?*

Animal Type(s) Please make between 1 and 6 selections from the choices below.

Pet(s)/Stray(s) Breed*

Please give us a description of the pet(s)/stray(s) including coat color and pattern. You will also need to email us a picture of the animal(s) to spca_rescue@yahoo.com within 24 hours of completing this intake request form.*

What is the sex of the pet(s)/Stray(s)? If more than one be sure to list sex of each like Stray Puppy 1 - Male, Stray Puppy 2 - Female, Stay Momma Dog - Female.

Is the pet(s)/Stray(s) spayed or neutered? If a stray female dog or cat and you are not sure just put unknown.

What is the animals coat length?
Choose all that apply: Long Hair Medium Hair Short Hair

What is the animals coat type?
Choose all that apply: Curly Rough Smooth Wavy Wiry

What type of ears does the animal(s) have?
Choose all that apply: Cropped Drooping Erect Tulip

What size is the animal(s)?
Choose all that apply: Small (Under 25 lbs) Medium (26 to 50 lbs) Large (51 to 75 lbs) X Large (Over 75 lbs)

What is the age of the animal(s)? If this is a stray(s) put your best guess.

Is this foster pet housebroken (and/or crate trained) if a dog? If a cat, litter box trained?

Is this animal(s) good with children?

Is this animal(s) good around other animals?

If this animal(s) is a dog and has been tested for Heartworm enter the date and results below. If this animal(s) is a cat and has been tested for FIV and Feline Leukemia enter date and results below. For both of above enter the clinic name, phone number and the name of the person that the records are under.

If this animal(s) has had any vaccinations in the last 12 months please enter the date, type, clinic name, clinic phone number and persons name the records are under below.

Please enter any other medical history for the animal(s) below. If spayed or neutered include name of clinic where surgery was done, their phone number and the date. If the animal is currently ill or injured please describe below.

Please note any observations you have made about the animal(s) below that you want us to know.

If this is a stray animal have you had it checked for a microchip? Any Vet Clinic can scan for a microchip and will do so at no charge to you. Check N/A if this is an animal owned by you.

If this animal(s) has a microchip enter the number below.

If this is a stray(s) animal you have picked up was it wearing a rabies tag on its collar? If this is an animal(s) owned by you check the N/A box.

If the animal(s) is wearing a rabies tag please enter the information from the tag below: (Enter Tag Number, Year, Clinic Name, Clinic Phone Number)

If this animal(s) is a stray does it have any type of identification on its collar if wearing one and if so enter all information below:

If we have room for this animal(s) in our adoption program are you willing to foster until we can find an approved adopter?

Any additional comments.

How did you hear about us?*