Animal Evacuation /SIP Request Form

ANIMAL EVACUATION / SHELTER-IN-PLACE REQUEST

Small Companion Pets, Livestock, Poultry/Fowl & Equine
Incident Name:
(Ex. Creek Fire, Fresno Floods)
Date*

MonthDayYear
Are You The Legal Animal Owner?*

YesNo
What are you requesting for your animamls?

EvacuationShelter-in-Place Care

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)*
Emergency Contact Name*
Emergency Contact Phone (24/7)*
Are you animals at this address?

YesNo
If No, What is the Property Addres?
(Address where your animals reside )

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?

YesNo
Are You An Emergency Responder?

YesNo
If Yes what agency/ company?
(ex. Fresno County Sheriff's Office, Cal Fire, PG & E

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

Additional Information On the Small Companion Pets. If being SIP, provide are instructions
(ex. if pets need medications or special diet food - give location)

Additional Comments For The Evac/SIP 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 due to an emergency/disaster. The animal owner/agent hereby releases and holds harmless the CCADT, law enforcement agencies, animal control agencies, fire agencies, and any other emergency response agencies and their assigned personnel involved with the disaster animal response from any and all liability from the evacuation, care, sheltering, 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.

In addition, when evacuation orders are lifted and animal owners can return home, please make arrangements for your pets to be picked up within 24 hours. If more time is needed, please contact CCADT at evac@ccadt.org.
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)*

I Agree to the aboveI Disagree to the above
Signature*
Should be Empty:

ANIMAL EVACUATION / SHELTER-IN-PLACE REQUEST