Dog Guardianship Form Step 1 of 4 25% Pet Guardianship Dog Enrollment Form*Thank you for taking the responsible step to enroll your beloved pet in Yavapai Humane Society’s Pet Guardianship Program. Dogs can’t talk, so they can’t tell us where or with whom they would like to live. To ensure that their home is a safe, happy & appropriate place for your dog to live, we need you to fill out this form in as much detail as possible. Detail & honest information from you is crucial to our placement process, so please take the time to fill in this profile with care & accuracy. Undesirable behaviors & medical issues do not necessarily create problems, however, not disclosing those problems definitely does. Inaccurate or incomplete responses can undermine the safety & happiness of both your dog & the new adopting family. If there are any questions that are unclear or that you are uncomfortable responding to for any reason, please ask to speak directly to one of our helpful staff about the issue. First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Dog's Name*Dog's Age*Dog's Gender* Male Female Dog's Breed*Dog Status* Spayed Neutered Intact Has dog been vaccinated within the past year?* Yes No Name of Veterinary Facility*How long have you had the dog?* Less than 1 year 1-3 years 3 or more years Where did you obtain this dog?* Yavapai Humane Society Other Shelter Breeder Pet Store Friend Found Rescue Group Newspaper Other To your knowledge, how many homes has this dog had before living with you?*Please list the ages and sexes of the people this dog has lived with:*Would you recommend placing this dog in a home with children under 10 years of age?* Yes No Not sure Please explain your recommendation:*If this dog lived with children under 8 years of age, how did they interact? (Check all that apply):* Dog actively avoided children Dog growled at children Children could pet the dog Ignored each other Played together Gentle/Affectionate Jump on / knock over Unknown Please tell us what other animals your dog has lived with (check all that apply):* Male Dog(s) Un-Neutered Female Dog(s) Un-Spayed Male Dog(s) Neutered Female Dog(s) Spayed Cat(s) Never lived with other animals What has been your dogs experience with other dogs in your home or outside of your home?* Bullies Frightened of Friendly/Playful Never around other dogs Growls/Snaps Shy Curious Unknown Lunges on leash Ignores Other: Please explain below Would you recommend placing this dog in a home with other dogs? Please explain below:*How does you dog interact with cats? (Check all that apply):* Chases Curious Friendly Never around cats Barks/lunges at cats Ignores Gentle Unknown Has injured/killed Frightened of Other Would you recommend placing this dog in a home with cats? Please explain below:*How often does your dog go to the bathroom inside your home? (check all that apply):* Every day Once a month Only when a puppy When yelled at If left too long Only when not home Marks inside Never had inside accident Goes while crated Other - Please explain below If your dog chews, what does he/she like to chew on? (check all that apply):* Chews furniture Chews socks/clothing Only chews toys Doesn't chew at all Chews at fences Chews when not home Chews rawhide/bones Chews at doorways/windows Steals items, then chews them Other - Please explain below: What does your dog do when you try to take an item away?*Where is your dog kept when you’re home? (check all that apply):* Always outside Sometimes outside Crate/Kennel Loose in the house In garage Confined to a room Kept chained outside In basement Other - Please explain below How many hours a day is your dog left alone?* More than 10 hours 8-10 hours 5-8 hours 0-5 hours Never left alone Other - Please explain below How do you confine your dog to your yard? (check all that apply):* None - dog runs free Partial fence Complete fence Stockade/privacy fence Chained to dog house 6 foot fence 5 foot fence 4 foot fence Other - Please explain below: Has your dog ever escaped? if so how? (check all that apply):* Climbs the fence Runs away if off leash Does not escape or run away Opens latch Runs but comes when called Digs under/chews through fence Jumps over fence Other - Please explain below What type of training has your dog had?* Group obedience classes Professional/Private sessions Never attended any obedience classes Trained at home What commands does your dog respond to (Check all that apply):* Fetch Sit Stay Paw/Shake Down Heel Other More dog training informationAre there any particular people or things that your dog appears to be afraid of? (check all that apply):* Men Dogs Cars/Trucks Strangers Loud noises Children Women Cats Water Thunderstorms Vacuums/Brooms People in uniform Other What does your dog do that leads you to believe he/she is afraid?What circumstances or situations should be avoided that may cause your dog to growl or behave otherwise aggressively?Has your dog ever (check all that apply): Bitten Snapped Growled Snarled Other Was it at or over (check all that apply): Food Rawhide Toys Strangers Children Adults Other Animals Other Does your dog have any current, previous or recurring medical or behavioral problems? (please describe in detail):Is your dog currently on any medication? If so please list medications:How does your dog react while at the vets office? (check all that apply): Growls Cowers/Fearful Tries to escape Happy/Playful Snaps at vet Needs muzzle Passive/doesn't care Tolerates Other - Please explain below What part of your dogs body does he/she not like touched? (check all that apply): Feet Back Legs Head Tail Mouth Belly Other How does he/she respond? (check all that apply): Snaps Growls Lunges Urinates/defecates Struggles/attempts to escape Cowers Other - Please explain below What is the name of your veterinarian/veterinary clinic?What brand and type of food have you been feeding your dog?Please upload a photo or photos of your pet(s) Drop files here or I certify...I have the authority to enroll the above described animal in the Pet Guardianship Program. Upon my death or incapacitation, I hereby relinquish all rights of ownership, in the above-described animal(s) in favor of Yavapai Humane Society, and I agree that the animal(s) may be placed up for adoption, transferred to another animal welfare organization or humanely euthanized at the sole discretion of Yavapai Humane Society. I authorize the transfer of my animal’s information (as listed above) to a new owner when this animal is placed up for adoption. The information on this form is to the best of my knowledge, accurate & complete. I understand that every effort will be made to place the animal in a foster home while it awaits adoption, but it may be housed temporarily in the YHS Adoption Center. I understand that YHS will attempt to place my animals in the same home but also understand the most important thing is to have them in a loving home, even if it means they are separated. Date Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
