Intake Form Rescue Worker InformationName First Last Email PhoneGeneral InformationRescue Date(Required) MM slash DD slash YYYY Type of Intake(Required) New Intake Foster Home Move Tag Number (if known) Dog Name(Required) Does the Dog's Name need to be changed in Foster Care?(Required) Yes No Dog Gender Male Female Dog Breed(Required) Australian Terrier Border Terrier Cairn Terrier Min. Schnauzer Norfolk Terrier Norwich Terrier Scottish Terrier Westhighland White Terrier Mixed Breed Dog Color(Required) Black Black Brindle Grey Grey Brindle Red Red Wheaten Wheaten White Dog Age(Required) Dog Weight(Required) Microchip Number Microchip Company How did this dog come into rescue?(Required) Owner Surrender Shelter Breeder Release Born to a CPCRN Dog Other Was this dog previously in CP?(Required) Yes No Foster Home InformationFoster Home Name(Required) State(Required) AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Foster Home Email(Required) Foster Home Phone Numbers – Please list all phone numbers(Required) Is this a new foster home?(Required) Yes No Date Expected to Arrive(Required) MM slash DD slash YYYY Other InformationHas this dog been Vetted to CP standards?(Required) Yes No Please explain what needs to be done in Foster Care(Required)Which of the following medications were given while being vetted?(Required) Heartworm Preventitive Flea Preventative Worming Medicine No Medication Given During Vetting Heartworm Preventative Brand Date Given MM slash DD slash YYYY Flea Preventative Brand Date Given MM slash DD slash YYYY Worming Medication Brand Date Given MM slash DD slash YYYY What CP Supplies that need to be sent to the Foster Home?(Required) CP Tag Heartworm/Flea Preventative Panacur Leash Collar/harness Crate Bellyband Other Select AllPlease explain what other supplies are needed(Required)Health Concerns that Foster Home Team needs to be aware of:Behavior Concerns that Foster Home Team needs to be aware of:Have all dog records been sent to the Foster Home Manager?(Required)Reminder: Owner Surrender forms must be e-mailed to [email protected] Yes No CAPTCHACommentsThis field is for validation purposes and should be left unchanged.