RVHS/NPAS Shelter Intake Form: Dog
Requirements at Approved Intake:
This form is an application and does not guarantee any placement or intake status at Needy Paws Animal Shelter
Intake Requirements (please select all information you will submit):
Valid Photo ID
Owner Surrender Form (provided upon acceptance)
Medical Records including Rabies Certificate
Completed Profile to assist adopters with selecting a new pet (this application)
Intake Fee as Determined after Intake Exam
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OWNER SURRENDER INFORMATION
Email
*
example@example.com
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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DOG INFORMATION
1. Dog's Name:
*
2. Age or Birthday if known:
*
3. Gender:
*
Female
Male
4. Spayed/Neutered:
*
Yes
No
Unknown
5. Dog Size:
*
XS
Small
Medium
Large
XL
Other
6. Dog breed(s), if known
*
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This Application is for:
Stray/Abandoned Dog
Owner Surrender (My Personal Pet Dog)
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Dog Ownership History
1. Where did you acquire your dog?
*
2. How long have you had your dog?
*
3. What issues are you having with keeping your dog?
*
Pet's Behavior
Pet's Health
Owner's Health
Finances
Housing
Family
Other
For "Other" please explain below:
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MEDICAL & DIETARY INFORMATION
1. When was the last time your dog was seen by a veterinarian?
*
2. Name of clinic:
*
3. Phone Number:
*
Format: (000) 000-0000.
4. Dogs current medications:
*
5. Describe any past or present health problems or injuries:
*
6. List any allergies your dog may have:
*
7. Food and schedule:
*
Dry
Canned
Table Scraps
Prescription
Other
8. Feeding Schedule:
*
9. Brand(s):
*
10. Favorite treats :
*
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PERSONALITY PROFILE
1. What is your dog's personality like (select all that apply)?
*
Cuddly
Affectionate
Mouthy
Curious
Energetic/Active
Jumpy
Playful
Independent
Goofy
Talkative
Calm/Gentle
Outgoing
Shy
Couch Potato
Fearful
Other
2. What does your dog like to play with (select all that apply)?:
*
Ball
Frisbee
Kong/Treat filled toy
Squeaky/soft toy
Hard toy
Tug toy
Bone
Stick
Water
Laser pointer
His/her tail
Other dogs
Cats
Puzzle toy
Other
3. What commands does your dog know (select all that apply)?:
*
Sit
Stay
Down
Paw
Place
Rollover
Come
Fetch
Other
4. How do you exercise your dog (select all that apply)?
*
Leashed walks/runs
Play in yard
Dog park
Hiking
Daycare
Swim
None
Other
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HOME ENVIRONMENT AND BEHAVIOR
1. Including yourself, indicate the age ranges of people your dog has lived or interacted with:
*
Seniors
Adults
Children under 5 years
Children between 6-12 years
Children between 13-17 years
2. How does your dog react to children:
*
Friendly/Playful
Avoids
Fearful
Unpredictable
Roughhouses
Calm/Easygoing
Snappy
Gentle
Growls/Barks
Never been around
3. Please indicate which types of dogs your dog is compatible with:
*
Male
Female
Small
Medium
Large
Puppy
Adult
Senior
Special Needs (blind, deaf, disabled etc.)
4. Please indicate which types of cats your dog is compatible with:
*
Male
Female
Small
Medium
Large
Kitten
Adult
Senior
Special Needs (blind, deaf, disabled etc.)
5. Please indicate how your dog reacts to other animals, including animal type.
*
Future adopters will need to know if your dog is compatible with livestock and other animals on their property. Please be as specific as possible ("dog has chased chickens on multiple occasions").
6. How does your dog react around food, toys and treats with people?
*
Does nothing
Takes nicely
Takes roughly
Growls/Snappy
Other
7. How does your dog react around strangers?
*
Does nothing
Takes nicely
Takes roughly
Growls/Snappy
Other
8. Describe your dog's behavior when:
Rows
Calm
Excited
Fearful
Other
At a Dog Park
On Walks
In the Car
Grooming/Bathing/Nail Trims
Handled by a Vet
If you selected "Other" above, please explain below or type "N/A"
9. Does your dog display any of the following behavior(s)?
*
Escapes yard
Chews inappropriate things
Pulls on leash
Digs
Inappropriate noises
Chases Wildlife / Dogs / Cats / Joggers / Vehicles
Bicycles
Other
10. Is your dog potty trained/housebroken?
*
Yes
No
Partially
Only when crated
Puppy pads
11. Where does your dog live:
*
House
Apartment
Garage
Outside in yard/pen
Inside in crate/round pen
Other
12. Where does your dog sleep:
*
On furniture
Floor
Dog bed
On people
Outside in yard
Crate/gated area
Other
13. Where does your dog stay when alone:
*
Free in home
Inside garage
Outside in yard
Crate or gated area
Other
14. Is your dog frightened of anything?
*
Men
Women
Children
Strangers
Vet/Groomers
Fireworks
Thunder
Vacuum
Crate
Bikes/Skateboards
Cars
Loud voices/Yelling
Being left alone
Other
If "Other," please explain:
15. Please describe any body parts your dog does not like being touched and what is the reaction:
16. Is there any other information you would like us to know about your dog?
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Dog Bite Disclosure
Has this dog ever bitten a person or animal?
*
No
Yes (explain in detail below)
Dog Bite History (include dates & circumstances)
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FINAL STEPS!
Please upload images of the animal(s) you are requesting intake for
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I understand that this application is for information purposes only and does not guarantee intake at any time at Needy Paws Animal Shelter
*
Type "I agree"
I understand that any status I receive will be by email from intake@needypawsanimalshelter.org and no phone calls or other messages will be answered by our Intake team
*
Type "I agree"
I understand that I am responsible for an intake fee for this animal/litter and will pay immediately if this intake application is approved.
*
Type "I agree"
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