SAFE HARBOR LAB RESCUE INTAKE FORM
SAFE HARBOR LAB RESCUE INTAKE FORM
SAFE HARBOR LAB RESCUE INTAKE FORM
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<strong>SAFE</strong> <strong>HARBOR</strong> <strong>LAB</strong> <strong>RESCUE</strong><br />
<strong>INTAKE</strong> <strong>FORM</strong><br />
Name(s)________________________________________________________________________<br />
Home Street Address_____________________________________________________________________<br />
City_______________________ State_______ Zip__________ E-mail Address_______________________<br />
Day Phone (______)_________________________ Evening Phone (______)_______________________<br />
Best Time to Contact You?__________________ How did you hear about us?________________________<br />
Ages and gender of other people in the household (full or part-time) that dog has lived with______________<br />
______________________________________________________________________________________<br />
Other animals living in your home and your Lab’s reaction to them__________________________________<br />
Otherr regular visitors, children, elderly folks in your home and your Lab’s reaction to them_______________<br />
______________________________________________________________________________________<br />
Dog’s Name____________________________________ Is your Labrador a purebred dog? Yes<br />
No<br />
Is your Lab a mixed-breed dog? Yes No Does your Lab have AKC papers? Yes No<br />
Breeder/Kennel where dog was acquired______________________________________________________<br />
Has Breeder been contacted regarding “return of dog” policy? Yes<br />
No<br />
Does Lab have a Tattoo or Microchip? Yes<br />
No<br />
Date of Birth______________Age_______ Sex: Male Female Spayed/Neutered Yes No<br />
How long have you owned your Lab?___________<br />
Veterinary Clinic & contact information for Vet Records___________________________________________<br />
Is Lab current on the following vaccinations?<br />
DHLPP…………………………………………….<br />
Rabies……………………………………………..<br />
Bordatella…………………………………………<br />
Heartworm Test ………………………………….<br />
Heartworm Preventative Medication…………..<br />
Yes<br />
No<br />
Type________________________<br />
Please answer these questions about your Lab:<br />
Housetrained?……………………………………………….<br />
Yes No Comments:<br />
______________________________<br />
Version: 07/07/2002
Been obedience trained?………………………………….<br />
Obeys commands?<br />
Sit………………………………………..<br />
Down ……………………………………<br />
Off ………………………………………<br />
Stay …………………………………….<br />
Other …………………………………..<br />
Have good leash manners?……………………………….<br />
Grab person’s clothing/hands/arm with mouth?………..<br />
Ever snarled or barked at anyone?………………………<br />
Ever bitten anyone?………………………………………..<br />
Have contact with children?………………………………<br />
Have contact with other dogs?……………………………<br />
Have contact with cats? ………………………………….<br />
Ever snarled or barked at another animal?……………..<br />
Ever bitten another animal?………………………………<br />
Afraid of anything (thunder, fireworks, children)? ……..<br />
Chew destructively?………………………………………<br />
React well with strangers?……………………………….<br />
Stay in crate?………………………………………………<br />
Have free roam of the house?<br />
When person present………………………….<br />
When person away…………………………….<br />
Like to ride in the car?.................................................<br />
Get carsick?.................................................................<br />
Will the dog lay on his back & expose belly for you?...<br />
Act possessive of food or toys?...................................<br />
Overly protective of a family member?........................<br />
Like to be bathed?.......................................................<br />
Like to be brushed?.....................................................<br />
Any negative behaviors<br />
other than those mentioned above?.........................<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
Age(s): ________________________<br />
Reaction: ______________________<br />
Reaction: ______________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
When: ________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
Lab’s reaction to grooming, nail trimming, ear cleaning___________________________________________<br />
Circumstances for placing Lab with SHLR_____________________________________________________<br />
______________________________________________________________________________________<br />
Deadline date for re-homing your Lab________________________________________________________<br />
Pease define any other special considerations and/or comments here:<br />
______________________________________________________________________________________<br />
______________________________________________________________________________________<br />
______________________________________________________________________________________<br />
Submission of this surrender/intake application does not guarantee that your dog will be accepted into<br />
SHLR’s program.<br />
There is no service fee for placing your Lab. However, we do request and appreciate donations, as SHLR is<br />
a non-profit organization run entirely by volunteers. There are various costs incurred, such as telephone,<br />
advertising, and computer costs. And your donation is a tax-deductible contribution!<br />
Applicant Signature __________________________________________ Date________________________<br />
Version: 07/07/2002
Printed Name of Signature:_________________________________________________________________<br />
Co-Applicant Signature _______________________________________ Date________________________<br />
Printed Name of Signature:_________________________________________________________________<br />
You may fax this completed intake/surrender application to Safe Harbor Lab Rescue at (303)733-3394 or by<br />
mail to:<br />
Safe Harbor Lab Rescue<br />
601 16 th Street, #C-322<br />
Golden, CO 80401<br />
(303) 464-7777<br />
www.safeharborlabrescue.com<br />
Any questions regarding this application may be directed to Nicole at (303) 464.7777.<br />
Version: 07/07/2002
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