Date of Intake

MM

DD

YYYY

Options For Support (check all that apply) *

Permanent Surrender - Northern Animal Rescue Alliance

Assistance - City of Terrace Animal Shelter Boarding

Assistance - Spay/Neuter

Assistance - Vaccinations

Funding - Pet Food

Funding - City of Terrace Animal Shelter Boarding (completed Boarding Agreement)

Residing at the Transition House Pet Room

Other (please specify in comments)

Owner's Name (the rightful owner of the animal/s) *

First Name

Last Name

Spayed/Neutered *

Yes

No

Cats - Has your cat been tested for feline leukemia and FIV? *

Yes

No

N/A

Dogs - Has your dog been tested for heartworms/? *

Yes

No

N/A

Does your pet have any fleas or ticks? *

Yes

No

Don't know

Please check all that apply *

Gets along with cats

Gets along with dogs

Aggression towards people

Housebroken

Gets along with children

Cat - Litterbox trained

Destructive (claws/chews/etc.)

Has your pet every bitten anyone? *

Yes

No

Unknown

Does your pet have any dietary/food allergies? *

Yes

No

Unknown

Is your pet house-trained/litter trained? *

Yes

No

Would you like to learn about how trauma and abuse can impact your animal? *

Yes

No