Animal Evacuation /SIP Request Form

ANIMAL EVACUATION / SHELTER-IN-PLACE REQUEST

Small Companion Pets, Livestock, Poultry/Fowl & Equine
Date

MonthDayYear
Hour MinutesAM/PM Option
Incident Name:
(Ex. Creek Fire, Fresno Floods)
Are You The Animal Owner?
What are you requesting for your animals?

Animal Owner Information

Please answer the questions to the best of your ability. The fields with the * are required.
First Name
Last Name
Home Street Address
City
Zipcode
E-mail Address
Mobile Phone Number (24/7)
Are animals at your home address?
If not at home address, provide the property address where they located?
Security Gate/Door At Property?
If YES, how to gain access?
(ex. gate code)

Non-Owner Reporting Person

(Family member, neighbor, friend, emergency responder, etc.)
First Name (Reporting)
Last Name (Reporting)
What Is Your Relationship To Animal Owner?
(ex. family, friend, neighbor, etc.)
Mobile Phone Number (Reporting)
Email (Reporting)
Have You Made Contact With Owner?
Are You An Emergency Responder?
If Yes what agency/ company?
(ex. Sheriff's Office, Cal Fire, PG & E)

SMALL COMPANION PETS (Dogs, Cats, Guinea Pigs, Reptiles, etc).

Are any of the small pets aggressive? If yes, please explain which ones.
List the Animal #.
List any additional pets or if being sheltered-in-place, provide care instructions.
(ex. if pets need medications or special diet food - give location)

LIVESTOCK, EQUINE, POULTRY / FOWL

Are any of these animals aggressive? If yes, please explain which ones.
Additional Information on Livestock, Poultry/Fowl & Equine. If being sheltered-in-place, provide care instructions.
Provide Information to safely handle, transport, and/or provide SIP care for your animals.
Easy access for vehicles and horse/stock trailers to quickly enter and exit your property?
If No, where should they park to load your animals?
Are halters / leads available?
If Yes, where are they located?
Will your large animals, primarily equine be easily load into trailers?
Additional trailer loading information. If "NOT ALL OF THEM", please explain which ones may not easily load.
Add any other information that may be helpful to evacuation teams

Permission To Evacuate Animals

Liability Waiver Required
The animal owner/agent listed hereby requests emergency animal services from the Central California Animal Disaster Team (CCADT) for the animal(s) described on this form. The animal owner/agent hereby releases and holds harmless the CCADT and any emergency response agencies from any and all liability from the evacuation, care, sheltering, and/or sustained injury and/or death of the animal(s) during and following the incident.

It is the responsibility of the animal owner/agent to keep CCADT informed of where the animal(s) owner or agent can be contacted during and following the emergency/disaster event. Please contact CCADT at evac@ccadt.org if you have questions or text to (888) 333-EVAC (3822
I have read the above information before signing and fully understand the content, meaning and impact. Please click to agree or disagree. If you click Disagree, we will be unable to evacuate or provide shelter-in-place care for your animals(s)
Signature
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ANIMAL EVACUATION / SHELTER-IN-PLACE REQUEST