ARG Animal ID #:

ARG Volunteer ID#:

Date:

Animal Description: Species / Breed / Color/ Gender / Identifying characteristics - tattoo, scar, markings, etc.

Location:

In the face of a declared emergency, I am requesting the Animal Response Group take this animal in to custody, transport it as necessary, shelter it until the end of the disaster incident, administer medical care as necessary in the determination of a licensed veterinarian, and return it to the legal owner if that owner becomes known to the ARG within 6 months (180 days) of this date.

I understand that this animal may have been and will possibly be exposed to contagious diseases and other risks during the time it is in ARG's care. I agree to not hold ARG responsible for the health or death of this animal. I understand that the animal will be put into foster care at the end of the disaster incident if the owner has not claimed it by that time. I understand that if the owner is not found, or if the owner relinquishes ownership in writing to the ARG, or if the owner has not claimed this animal, then this animal will be adopted to a new owner 180 days from this date unless other arrangements are made in writing between ARG and the owner before that date.

This animal has bitten someone in the last 10 days [ ]

Victim's name:

Physician's name:

Phone #:

Address:

This animal has not bitten anyone in the last 10 days [ ]

Prior history of biting? [ ] Yes [ ] No

I do not know if this animal has bitten anyone in the last 10 days, it is not my animal [ ]

Known medications, vaccinations, health problems, diet information:
 
 

Is animal micro chipped:

Brand:

Location:

Number:

Confirmation: scanned [ ] Number

[ ] Not yet

ARG pre-scan: chip found, number

Brand

No chip[ ]

ARG chip implant:

Brand

Number

Comments:  
 

Please initial

Signature:

Date:

Time:

ARG witness signature:

ARG ID #:

Please also fill out an Admission Form. Thank You!