Peace of Mind Dog Rescue · Helping Paw Volunteer Assistance Application

Your Information

Name

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First Name

Last Name

Email

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Verify Email

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Email again

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Please enter the same email address again

Verify Email

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Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Home phone

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Cell phone

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What is your preferred means of communication?

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Home phone

Cell phone

Email

Text

Who is the legal owner of this dog?

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Dog owner's date of birth

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(mm/dd/yyyy)

What type of assistance are you requesting?

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Short term emergency foster care

Dog walking

Transportation to vet or groomer

Please describe your situation and why you need assistance

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How did you hear about us?

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Other

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Dog's Information

Dog's name

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Breed

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If your dog is a mix, list the one or two most prominent breeds

If you can, please supply one or two photos of your dog

Photo 1

Photo 2

Dog's weight

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Dog's age

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Dog's gender

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Male

Female

Is the dog spayed/neutered?

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Yes

No

Why not?

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E.g. can't afford, medical reason, didn't get around to it yet, wanted to have a litter, etc.

How long have you had this dog?

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Where did you get this dog?

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Has this dog ever bitten a person or another dog?

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Yes

No

Explain

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How quickly do you need assistance for this dog?

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When did this dog last see a vet?

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Can you provide medical records?

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Yes

No

Please give name of the vet clinic and person's name the records are under

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Does your dog have any current medical issues?

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What training does this dog have?

Check all that apply

House trained

Crate trained

Walks well on leash

Basic commands

Other

Explain other training

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How does your dog get along with other dogs in general? Are there particular types of dogs your dog doesn't get along with?

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How does your dog respond to dogs when out on a walk?

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For example: ignores, politely sniffs, gets excited, barks

How does your dog respond to people he/she meets in public for the first time?

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How does your dog respond to new people who come to the house?

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How does your dog respond to children?

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How does your dog respond to cats?

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What is your dog's energy level?

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For example: calm, needs a lot of exercise, doesn't have a stop button, settles at home nicely

How does your dog respond if you try to take away a bone, food dish, or favorite toy? Does he/she growl or snap?

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Where does your dog sleep at night?

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Is your dog indoors or outdoors during the day? How many hours is he left alone on a typical day?

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What kind of food does your dog eat?

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What is your dog allergic to, if anything?

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Does your dog have any past injuries or illnesses we should know about?

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Please list any medications your dog takes (or "none")

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Is your dog microchipped?

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Yes

No

Is there anything else you would like us to know about your dog (dislikes, fears, sensitive areas, etc.)?

Please upload a photo of your pet

Please upload a photo of you or a family member with your pet

Photo Release

I understand that public relations is an important part of POMDR’s ability to raise funds for people like me in need of assistance . On behalf of myself, my heirs, personal representatives, and executors, I allow POMDR to use any photographs taken of me or my pet or submitted by me for use in public relations efforts including print materials, website, and social media. Also, all photographs that I submit to POMDR will remain the property of the photographer. POMDR will have the rights to use these photographs for marketing materials or in any other ways that POMDR sees fit.

I accept the Photo Release

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Yes

No

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