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Application for Yankee Chihuahua Rescue Intake

Yankee Chihuahua Rescue and Adoption, Inc (YCRAA)

This form is the Intake Application. Please complete all required entries marked with a red asterisk *.
This form will not be able to submit without all the required questions answered.  Please be as detailed as possible.

Only residents of Maine, New Hampshire, Vermont, Massachusetts, Connecticut, and Rhode Island can be considered for intake of dogs.  Proof of residency is required.  We can not accept dogs outside of these areas.
Contact Chihuahua Rescue and Transport (CRT) for information about surrendering your Chihuahua in your area.

 BE AWARE:   We cannot / will not take in aggressive dogs or dogs that bite.  
We are a volunteer group and do not have the training to provide behavior modification.
For such animals we advise that you contact a Certified Applied Animal Behaviorist.

If you can not complete the application or have questions then please email us:

* First and Last Name 
* Home Street Address                                       City/Town                                        Zip Code

* State
   We can not accept dogs outside of these areas.
Contact Chihuahua Rescue and Transport (CRT) for information about surrenders in your area.

Mailing Address if different from Home address

* Home Phone: * Best time to call:
   Cell Phone: * Email Address
   Work Phone: * Dogs Name

   DOG'S HISTORY

* Where did the dog originally come from? 

* Is the dog registered with the AKC or CKC? Are the registration papers/pedigree available?

* Who is surrendering or releasing the dog? (Owner/Relative of owner/ if shelter or rescue group, please name)

* Reason for surrender/release?

*


   DOG'S PHYSICAL DESCRIPTION

* Age, Sex, When Spayed/Neutered

*

* Color, Markings, Coat Type (short or long hair)

* Any permanent identification? (ID, tattoo, microchip, tag?)


  DOG'S MEDICAL / HEALTH ISSUES

* Date of last vaccinations?  (mm-dd-yyyy)
* List of current vaccinations and their dates:
* Date of last veterinarian visit?  (mm-dd-yyyy)
* Reason for last veterinarian visit?
* List any current/past allergies, chronic illnesses, diseases, etc:

* Name, Address and Telephone of dog's primary veterinarian


   DOG'S BEHAVIOR (TEMPERMENT)

We cannot / will not take in aggressive dogs or dogs that bite.
We are a volunteer group and do not have the training to provide behavior modification.
For such animals we advise that you contact a Certified Applied Animal Behaviorist.

* General description of behavior: (For example: Confident/shy? Friendly/reserved? Fearful? High/low activity level? Submissive? Aggressive? Quiet/noisy?)

* Is the dog house trained?
     		Additional comments about the dog:

How does the dog typically respond to ...

Members of house / Roommates?
Men vs. Women?
Children vs. Adults?
Visiting friends and family?
Strangers coming into the house?
Other dogs living in the house?
Cats?
Other animals in home (specify)?

How does the dog typically respond during walks ...

Strangers met on walks?
Other dogs met on walks?
Male dogs vs. Female dogs?
Big dogs vs. Small dogs?
Other animals during walk (cats, birds, squirrels / chipmunks, etc.)?

How does the dog typically respond with professionals ...

At the veterinarian
At the groomer's or boarding kennel?
When groomed, nail trimming, bathing?

How is the dog's temperment ...

How does the dog respond to commands / Obedience?
What does the dog especially like/enjoy?
What does the dog dislike or fear?
We cannot / will not take in any aggressive dogs or dogs that bite.
Has the dog shown aggression toward people/children?
Has the dog shown aggression toward other animals?
If yes to either question above, then please detail all circumstances of its aggression.

" Aggression " refers to the dog’s hostile or threatening behavior -- including lunging, growling, barking, snapping, or biting.
Equipment, toys, other items sent with dog.

 IMPORTANT:   By typing your full name in the signature field below, you acknowledge that your typed name holds the same legal standing as your handwritten signature. By e-signing this form, you confirm that the information provided is accurate to the best of your knowledge and belief. Furthermore, your e-signature authorizes us to verify this information, including contacting your references and veterinarian. You also consent to your veterinarian sharing information about the health records of your current or past pets with our organization.

Please don't surrender a dog to anyone unless they display a badge with the YCR logo and photo ID.

Everyone from Yankee Chihuahua Rescue will always display a Rescue Photo ID Badge while conducting rescues, home visits and/or general rescue business. We will provide and leave you a signed surrender form with the volunteer's name who takes the dog.

* Signature:  

Where did you hear about us? Comments?


Incomplete applications will not be considered.  Please provide much detail for consideration.

Incomplete applications require time to follow up and all requested information is important.
When you have answered all the required questions:

Submit Application:                     Reset Form:    CAUTION This will clear the entire form.

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