Ruff Haven Crisis Sheltering Application

Ruff Haven Crisis Sheltering Application
I understand the Ruff Haven Crisis Sheltering program is for pet owners who are in a crisis situation (hospitalization, mental health treatment, domestic violence, eviction, etc.) and will lose custody of their pet without our services. Situations of personal choice (do not want to pay for boarding, moving for a job, building a house, in a temporary situation but want more room for their pet, etc.), or knowingly violating the terms of your leasing agreement, do not qualify for our program.*

Yes
Owner 1 Information
Name*
Associated Person

First NameLast Name
Date of Birth (You must be 18 years old for our program)*

MonthDayYear
Date
Current Address*
City*
Zip*
Phone*
Email
example@example.com
What is the best way to contact you? (select all that apply)

TextEmailPhone Call
Occupation
What are your preferred pronouns?

He/HimShe/HerHe/TheyShe/TheyThey/ThemOther
Have you served in the military?

YesNo
Are you Hispanic, Latino/a, or Spanish origin?

YesNoPrefer not to answer
Which one or more of the following would you say is your race?

WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderPrefer not to answer
Have you ever used opiates(heroin, oxycontin, morphine, etc.) not as prescribed or to get high? *This question is required for grant funding, so that we can continue to provide free services.

YesNoPrefer not to answer
If you are filling out this application for a loved one, please be sure to put THEIR name, instead of yours. We also MUST be able to speak with the owner or Power of Attorney. We legally can't accept pets without owner permission.

I understand
I understand the Ruff Haven Crisis Sheltering Program is for pet owners who are in a crisis situation(hospitalization, mental health treatment, domestic violence, etc.) and will lose custody of their pet without our services. Situations of personal choice(not wanting to pay for boarding, moving for a job, building a house, in a temporary situation, but want more for their pet, etc.) do not qualify for our program.

I understand
I understand that Ruff Haven is unable to accept evictions due to lease violations in which the pet agreement was violated(pets not on the lease, bites, running at large, over size limit, etc.).

I understand
Emergency Details
Which of the following best describes why you are applying for this program?*

Domestic ViolenceHospitalizationHousingTreatmentIncarcerationOther
Why are you requesting temporary housing accommodations for your animal/s?:*
What is the estimated length of time you are requesting care? *
What other methods have you used to try to find care for your pet(s?)*

FamilyFriendsBoardingOther
If we are unable to provide sheltering services for your pet, what is your plan for them?

My pet(s) can stay with a family member or friendMy pet(s) can stay with a neighbor or community contactI have access to paid boarding servicesI would need to surrender my pet(s) to an animal shelter/rescueOther
Domestic Violence
I do not currently have any active domestic violence cases and have not been convicted of any domestic violence–related offenses. (We are unable to provide sheltering services to individuals with these offenses)

I do not have any current domestic violence cases and have not been convicted of any domestic violence-related offensesOther
If you are a victim of domestic violence, please also answer the following questions:
What is your relationship to the abusive person?
Do you think the abuser will try to find the animal(s)?

YesNoDon't Know
Does the abusive person have any legal claim to the animal(s)?

YesNoDon't Know
Do you have a protective order against the abusive person?

YesNo
Date order granted

MonthDayYear
Date
Order number
Required Waivers
Do you consent to having your pet/s spayed or neutered if the procedure has not already been performed?*

YesNo
Will you have regular access to your phone or e-mail to check-in with a Ruff Haven volunteer on a weekly basis? (Other than in cases of incarceration or treatment blackout periods)*

YesNo
Do you agree to release any information regarding your treatment or hospitalization status to Ruff Haven in order to facilitate reunification with your pet?*

YesNo
If you answered "No" to any of the previous three questions you are ineligible for our program. Please do NOT continue with the remainder of the application.
Animals are cared for in a boarding facility or in a private foster home, most of which have pets of their own. Dogs must be able to live successfully with other dogs. We are unable to accept aggressive animals. Does your dog get along well with other dogs?

YesOther
I acknowledge that admission to sheltering may cause stress for my pet and may expose them to diseases or conditions that could adversely affect their physical or mental health.*

Yes
In the event of behavioral deterioration, do you agree to pick up your animal should our staff no longer deem safe to handle?*

Yes
Can you commit to pick-up your pet/s within 72 hours of your contract’s expiration?*

Yes
*Animals whose owners do not make pick-up arrangements in a timely manner are subject to being considered owner relinquished and will be placed up for adoption after the contract’s expiration.
Animal Information Animal #1
Name*
Breed*
Sex*
Age and/or Birthdate if known*
Is this animal spayed or neutered?*

YesNoDon’t Know
Is your pet currently up to date on their vaccinations?*

YesNoDon’t Know
Is your pet microchipped?

YesNoDon't Know
Can your pet live safely with other animals?*

YesNo
If you answered no please explain:
Approximate Weight*
Color*
Unique characteristics:
How long have you had this pet?*
Where did you obtain this pet?*

Friend/family memberKSL/onlineStray/found animalPurchased(breeder, pet store, etc.)Humane Society of UtahBest Friends Animal SocietyCAWSRescue RoversNuzzles & Co.Animal ShelterOther
Medical Information
Veterinary Office
Veterinarian’s Name
Address
Phone Number
When was your pet last seen by a veterinarian?*
Please list all current medications, allergies, or ailments:*
Feeding Information
What type of food does this pet eat?*

WetDry
What brand/s are you currently feeding?
Amount Per Feeding
Feeding schedule
Preferred treats and toys
If your pet has dietary restrictions will you be able to provide their food?*

YesNo
Lifestyle & Behavior Information
Present housing situation:*

IndoorOutdoorOther
For dogs: How often do you take them on a leashed walk?*
Is your pet house trained or litter box trained?*

YesNo
Is your pet crate trained?*

YesNo
Will your pet chew or scratch furniture, clothing, doors when left unattended?*

YesNo
Describe your pet’s personality in three words:*
Activity level:*

Very activeModerately activeNot active
Does your pet have a history of escaping or jumping fences?*

YesNo
If yes, how do they try to escape?

DiggingDoor DashingOther
What cues/commands does your pet know?
Is your pet afraid of any of the following?*

ThunderstormsFireworksCarsOther
What is your pet’s reaction when they are afraid:*

Avoid/HideGrowl/Show teethLunge/Snap/Bite
How does your pet react to new people/strangers?*
Has your pet successfully lived with children?*

YesNo
If yes, what ages?
How does your pet react to unknown animals?*
How does your pet behave when undergoing a routine veterinary examination?*
Has your pet successfully lived with other animals?*

YesNo
If “Yes” what kind:
Has your pet ever bitten or scratched a person?*

YesNo
If yes, when did the incident occur?
What were the circumstances of the incident?
List any additional behavioral issues that we should be aware of:
Anything else we should know?
Animal #2
Name
Breed
Sex
Age and/or Birthdate if known:
Is this animal spayed or neutered?

YesNoDon’t Know
Is your pet currently up to date on their vaccinations?

YesNoDon’t Know
Is your pet microchipped?

YesNoDon't Know
Can your pet live safely with other animals?

YesNo
Type a question
Coloring
Approximate Weight
Unique characteristics:
Where did you obtain this pet?

Friend/family memberKSL/onlineStray/found animalPurchased(breeder, pet store, etc.)Humane Society of UtahBest Friends Animal SocietyCAWSRescue RoversNuzzles & Co.Animal ShelterOther
How long have you had this pet?
Medical Information
Veterinarian’s Name
Address
Phone Number
When was your pet last seen by a veterinarian?
Please list all current medications, allergies, or ailments:
Feeding Information
What type of food does this pet eat?

WetDry
What brand/s are you currently feeding?
Amount Per Feeding
Feeding schedule
Preferred treats and toys
If your pet has dietary restrictions will you be able to provide their food?

YesNo
Lifestyle & Behavior Information
Present housing situation:

IndoorOutdoorCar
For dogs: How often do you take them on a leashed walk?
Is your pet house trained or litter box trained?

YesNo
Is your pet crate trained?

YesNo
Will your pet chew or scratch furniture, clothing, doors when left unattended?

YesNo
Has your pet successfully lived with children?

YesNo
If yes, what ages?
Describe your pet’s personality in three words:
Activity Level:

Very activeModerately activeNot active
Does your pet have a history of escaping or jumping fences?

YesNo
If yes, how do they try to escape

DiggingDoor DashingFence JumpingOther
What cues/commands does your pet know?
Is your pet afraid of any of the following?

ThunderstormsFireworksCarsOther
What is your pet’s reaction when they are afraid:

Avoid/HideGrowl/Show teethLunge/Snap/Bite
How does your pet react to unknown animals?
How does your pet behave when undergoing a routine veterinary examination?
Has your pet successfully lived with other animals?

YesNo
If “Yes” what kind:
Has your pet ever bitten or scratched a person?

YesNo
If yes, when did the incident occur?
What were the circumstances of the incident?
List any additional behavioral issues that we should be aware of:
Anything else we should know?
Information on any additional animals:
NOTE: Ruff Haven can usually only admit two animals per family
Veterinary Office
How did you hear about Ruff Haven Crisis Sheltering?*

Humane Society of UtahStreet Dawg Crew of UtahHomeless Resource CenterFacebook/Social MediaTreatment CenterFriendSocial WorkerVASalt Lake County Animal ServicesNuzzles & CoPoliceOther
Have you used Ruff Haven's Sheltering program before?*

NoYes
Are you currently working with a social services agency?*

YesNo
If yes, which social services agency are you working with?
**Please note it may take up to 24 hours to return messages and review applications.
Owner #1 Signature
Date

MonthDayYear
Date
Name
Owner #2 Signature
Date

MonthDayYear
Date
I understand that I must have an appointment to receive services and will be turned away without one.*

Yes
Please attach a photo of your pet, along with any vaccination records you have.

Browse Files

Cancelof
Should be Empty:

Ruff Haven Crisis Sheltering Application

Owner 1 Information

Emergency Details

Domestic Violence

Required Waivers

Animal Information Animal #1

Medical Information

Feeding Information

Lifestyle & Behavior Information

Animal #2

Medical Information

Feeding Information

Lifestyle & Behavior Information