719-395-2737
DONATE
About Us
Our Story
Life-Saving Statistics
Newsletters
News
Happy Tails Blog
FAQ
Board of Directors
Staff
Employment
Adopt
Dogs
Cats
Other Critters
Before You Adopt
How To Adopt
Services
Community Resources
Local Pet Resources
Kitten Resources
Pet Emergency Medical Fund
Pet Food Pantry
Emergency Pet Boarding
Pet Behavior Support
Spay, Neuter & TNR Programs
Pet Cremation Services
Relinquishing Your Pet
Lost & Found Pets
Get Involved
Adult & Youth Volunteers
Foster Program
Group Volunteer
Do It Yourself Projects
Volunteer FAQ’s
Events
Sponsor or Host an Event
August Matching Campaign
Comanche Drive In
Tails on the Trail
Good Pet/Bad Portrait
Feline & Fido Photo Contest & Calendar
Community Microchip and Pet ID Tag Clinc
Contact
CONTACT US
[contact-form-7 id="No contact forms found" title="Contact"]
Service In Form
Home
»
Service In Form
Service In Form
**This information is kept confidential**
Service In Form
Animal Information
Animal's Name
*
Today's Date
*
MM slash DD slash YYYY
Species (please circle)
*
Cat
Dog
Other
Sex
*
Male
Female
Animal Age
*
Sterilization
*
Spayed
Neutered
Intact
Unknown
Breed
*
Purebred? Mixed Breed?
*
Purebred
Mixed Breed
Coloring
*
Markings
What is the animal's current diet?
*
Reason for Intake
*
Behavior
How is this animal towards other dogs?
*
Good
Not Good
If the dog is dog-social, do you agree to allow AVHS to let your dog socialize with other dogs?
Yes
No
Initials
*
How is this animal towards cats?
*
Good
Not Good
If the cat is cat-social, do you agree to allow AVHS to let your cat socialize with other cats?
*
Yes
No
Initials
*
Has this animal ever tried to escape its yard or enclosure?
*
Yes
No
If Yes, how?
Does this animal have any behavior issues?
*
Yes
No
If Yes, what?
Has this animal ever harmed a person?
*
Yes
No
If Yes, what was the situation?
Has this animal bitten a person in the last 10 days?
*
Yes
No
If yes, please describe the situation in detail. (if no please write N/A)
*
Use the following space to tell us more about this animal:
*
Medical Information
Veterinarian:
*
Vet Phone Number
For Dogs, is animal current on following vaccines: Bordatella, Distemper-Parvo, Rabies?
*
Yes
No
For Cats, is animal current on following vaccines: Distemper (FVRCP), Rabies?
*
Yes
No
If you answered yes, AVHS will need veterinary records to verify vaccines given.
*
OK
Does this animal have any known health issues or injuries?
*
Yes
No
If yes, please describe: (if no simply put N/A)
*
If this animal is currently on any medications, please state the name of the medication(s) and provide any treatment instructions:
Personal Information
Owner/Client Name (as it appears on Drivers License)
*
First
Last
Phone
*
Email
*
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
Organization Name (If applicable)
Organization Primary Contact Name:
First
Last
Organization Contact's Number:
Photo of your Drivers License or ID
Max. file size: 64 MB.
Address of organization
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Service Agreement
By signing below, I certify that my animal is current on species-species vaccines. If veterinary documentation of current vaccines is not provided, I agree to allow Ark-Valley Humane Society to give the necessary vaccines as needed under the financial expense of me, the owner. I also authorize to allow Ark-Valley Humane Society to give my animal medication or provide medical treatment as needed or as instructed by me the owner. Medications should be in the original container, indicating the pet's name, medication name, dosage and prescribing veterinarian. I understand that, in the event my animal appears to be ill or significant risk of experiencing a medical problem, Ark-Valley Humane Society will attempt to contact me and/or my emergency contact for instructions prior to seeking veterinary care. If I cannot be reached, I agree that Ark-Valley Humane Society may use its reasonable discretion in seeking veterinary care and I will be responsible for all related expenses. I understand that Ark-Valley Humane Society will not be liable for the actions and decisions of the veterinarian. I understand that there are inherent risks associated with my animal being in a shelter environment and I agree that Ark-Valley Humane Society will not be liable for any claims of injury, illness, damage or death to my animal during its stay and that under no circumstances will Ark-Valley Humane Society be liable for consequential damages. I understand that if my animal is not picked up from Ark-Valley Humane Society within 5 days of the below stated pick up date, without other arrangements made, my animal will be considered abandoned and becomes the legal property of Ark-Valley Humane Society to be outcomed in the manner that Ark-Valley Humane Society determines.
Signature
*
Date
*
MM slash DD slash YYYY
Pick Up Date
*
MM slash DD slash YYYY
Boarding Fee to be Collected ($15/night)
CAPTCHA