Application for Foster Intake

Yankee Chihuahua Rescue and Adoption, Inc (YCR)

Application for Yankee Chihuahua Rescue Intake

Only residents of Connecticut, Rhode Island, Maine, Massachusetts, New Hampshire, and Vermont
can be considered. We can not accept dogs outside of these areas. Contact Chihuahua Rescue and Transport (CRT) for information about surrendering your Chihuahua in your area.)
If you can not complete the application, Please Email; YankeeChihuahua@gmail.com

*Date

*Name

*Street Address

*Town/City, State, Zip

*State
CT / NH / MA / ME / RI / VT

Please note; 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 Cell Phone Work Phone
*Best time to call, and prefered phone

*Email (YCR preferred contact method)

*Dogs Name

DOGS 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?

** Other Information (previous homes, general situation in previous homes, family type)

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?)

MEDICAL/HEALTH ISSUES
** How is the dogs health? Allergies, chronic illness or disease, etc

Up to date on vaccinations?	Yes No
Heart worm/Lyme negative?	Yes No
On heart worm preventative?	Yes No
On flea/tick preventative?	Yes No
May we contact the dogs vet?	Yes No

**Name and Phone Number of Dog's Veterinarian

BEHAVIOR
Please Note. We can not take in aggressive or dogs that bite. We are a volunteer group and do not have the training to provide behavior modification. Please 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? Yes No
Comments

How does the dog typically respond to . . .?

Strangers met on walks?
Strangers coming into the house?
Men vs. Women?
Children vs. adults?
Other dogs in the house?
Other dogs met on walks?
Big dogs vs. small dogs?
Male vs. female dogs?
Friends and family members?
Cats?
Other animals?
At the groomer's or boarding kennel?
At the Vets
When being groomed, nail trimming, bathing?
How does the dog respond to commands /Obedience?
What does the dog dislike or fear?
What does the dog especially like/ enjoy?
Has the dog snapped at, nipped, or bitten people?	Please contact a Certified Applied Animal Behaviorist.
Has the dog shown aggression toward other animals?
If yes, what were the circumstances?
Were other animals harmed?the dog?
Equipment, toys, other items to be sent with dog.

I represent that the information that I have provided on this form is the truth to the best of my knowledge and belief and hereby give my permission for you to use any of the above information to confirm that all information provided is the truth. This means you give us your permission to call references and that you allow us to contact your vet and that you hereby give consent for your vet to release the information in your current/past pet's health files to us.
* Signature *
This is an Electronic Signature representing your acknowledgement everything above is true.

Where did you hear about us? Comments?

Submit Application:

We at Yankee Chihuahua Rescue display a Rescue Photo I.D. Badge while conducting rescues, home visits and/or general rescue business. We will provide, and leave a signed surrender form with you with the Volunteer's name.

Please don't surrender a dog to anyone unless the volunteer displays a badge with the YCR logo and photo I.D.

To Reset the Application and start over:

If you are not returned to a 'Thank-You' Page after submitting this form, Your application did NOT go through.
If you experience problems submitting the form, Please copy the form at;
Google Documents and Email it to;
YankeeChihuahua@gmail.com

(2010)