Foster Dog Intake Form

Yankee Chihuahua Rescue and Adoption, Inc (YCRAA)

Please complete all required fields marked with *. Only residents of Maine, New Hampshire, Vermont, Massachusetts, Connecticut, and Rhode Island.

We cannot / will not take in aggressive dogs or dogs that bite.

Contact Information

* First and Last Name

* Home Street Address

* City/Town

* Zip Code

* State

Mailing Address (if different)

* Primary Phone

* Email Address

Secondary Phone

* Dog's Name

* Best time to call

Dog's History

* Where did the dog originally come from?

* Is the dog registered with AKC or CKC? Registration papers available?

* Who is surrendering/releasing the dog?

* Reason for surrender/release?

* Other information (previous homes, family type, etc.)

Dog's Physical Description

* Age, Sex, When Spayed/Neutered

* Size (height/weight)

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

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

Dog's Medical / Health Issues

* Date of last vaccinations

* Date of last veterinarian visit

* List of current vaccinations and dates

* Reason for last veterinarian visit

* List any current/past allergies, chronic illnesses, diseases

* Veterinarian name, address, telephone

Dog's Behavior (Temperament)

* General description of behavior

Confident/shy? Friendly/reserved? Fearful? High/low activity level? Submissive? Aggressive? Quiet/noisy?

* Is the dog house trained?

Yes No

Additional comments about the dog

How does the dog typically respond to:

At home

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)?

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)

With professionals

At the veterinarian?

At the groomer's or boarding kennel?

When groomed, nail trimming, bathing?

Temperament

Response to commands / Obedience?

What does the dog especially like / enjoy?

What does the dog dislike or fear?

Aggression Assessment

"Aggression" refers to hostile or threatening behavior — including lunging, growling, barking, snapping, or biting.

* Has the dog shown aggression toward people/children?

* Has the dog shown aggression toward other animals?

* If yes, detail all circumstances

Equipment, toys, or other items sent with dog

Signature

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.

* Signature

Where did you hear about us? Comments?

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