Safe Haven - Application Form - PEI Humane Society

Safe Haven

Animal Protection

How to apply for Safe Haven

Safe Haven is an emergency animal housing program. This program is for emergencies only – it is not a boarding program.

The application form is embedded below. Please fill the application in.

We will contact you once your application is received.

Safe Haven Application Form

Form used by clients incoming to Safe Haven.

Name(Required)

Please provide your name, even if different from the animal's owner.

First Last

Ownership Acknowledgement(Required)

By checking this box, I (the above named individual) claim to be the legal owner/guardian of the animal named later in this document.

Permission(Required)

By checking this box, I acknowledge that I am giving the PEI Humane Society permission to take over care of the animal for which I am the owner/guardian starting on the below-noted date.

The date I wish to transfer the below described animal into the care of the PEI Humane Society:(Required)

The date I wish to remove the animal from the care of the PEI Humane Society:(Required)

This date can be subject to change depending on your personal situation. Please see details about time-in-care below in this document.

Agreement Change Declarations(Required)

By checking this box, I hereby acknowledge that I understand and agree that I have the opportunity to ask for an extension of care for my animal(s) but the PEI Humane Society may not be able to accommodate my request.

By checking this box, I hereby acknowledge that that if I do not reclaim my animal(s) by the above-stated date, or make other arrangements with the PEI Humane Society, it will be deemed I have surrendered my ownership rights and interests of any kind to the animal(s) below.

Ownership and Confidentiality Agreements(Required)

By checking this box, I hereby acknowledge that I understand and agree that the PEI Humane Society will return my animal(s) only to me, unless I designate a person to claim my animal in my absence, in which case I will notify the PEI Humane Society at least twelve (12) hours beforehand. If I do designate a person to claim my animal(s), I understand that the PEI Humane Society will not release my animal(s) to anyone, pending a court order or at the request of police or RCMP.

By checking this box, I hereby acknowledge that I understand and agree that the PEI Humane Society’s Safe Haven program is a completely confidential program, and I will not divulge any information regarding the location of my animal(s) enrolled in this program to anyone. I understand and agree that if I inform anyone that my animal(s) are enrolled in this program – particularly abusive or dangerous persons – then this agreement is null an void and I will be notified as such. Upon nullification, I will need to pickup my animal(s) within the same day. Should I fail to reclaim my animal(s) on the designated day, my animal will be considered to have been abandoned. At such a time, the PEI Humane Society has the absolute right and authority to place said animal(s) into new homes or otherwise find appropriate permanent placement.

By checking this box, I hereby acknowledge that I understand and agree that my animal(s) may (or will) be fostered at the PEI Humane Society, a boarding kennel, a veterinarian’s office, or with a qualified foster volunteer. Should the PEI Humane Society choose to kennel my animal(s) at an alternate location, I will not hold any such boarding kennel, veterinarian’s office, their staff, or the qualified foster volunteer liable for any illness, or injury of my animal(s).

Animal Care Declaration(Required)

By checking this box, I hereby acknowledge that I understand and agree that the PEI Humane Society will provide the best care possible for the animal(s) during the sheltering period but notes there are inherent dangers and risks when dealing with any animal, including but not limited to changes in the animal’s behaviour, weight, or contraction of contagious disease. Accordingly, I hereby absolve the PEI Humane Society, (including its employees, successors, assigns, directors, officers, agents, or volunteers) from any and all claims, obligations or liabilities of every kind relating to or arising from the fostering my animal(s). In addition, if said animal(s) bites or injures any human or other animal, I will hold harmless, indemnify and protect the PEI Humane Society from any claim or suit filed by anyone as a result of such an incident.

By checking this box, I hereby acknowledge that I understand and agree that the PEI Humane Society and/or its designated off-site foster care provider will provide daily food, water, socialization, exercise and basic preventative care for my animal(s).

By checking this box, I hereby acknowledge that I understand and agree that the PEI Humane Society reserves the right to make sound medical decisions for my animal(s) while they reside in their care. I also understand that I will be informed and consented for any non-emergency procedures the PEI Humane Society deems necessary. In the case of an emergency procedure being needed, I will be informed at the earliest possible time but as it is an emergency, the PEI Humane Society will not wait for my permission but will instead proceed in my pet(s’) best interest.

Owner's/Guardian's Information

Your name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Safe Phone Number(Required)

This phone number should be a safe line you have access to where we can leave you a voicemail if need be.

Alternate Phone Number

Employer's Name

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer's Phone Number

Emergency Information

Emergency Contact Other Than Owner(Required)

This person should be able to get ahold of the owner in an emergency situation if the owner is not available immediately.

First Last

Emergency Contact's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact's Phone Number(Required)

Other Important Information

This section is designed to ensure we're able to keep you, our staff, and your animal(s) as safe as possible throughout this process.

If this is a case involving domestic abuse, have the police been notified?(Required)

Yes

Not Applicable

Is there an abuser or other person the PEI Humane Society should be aware of who may come looking for your animal(s)?(Required)

Please explain. Please give as much detail as you're able to. If not applicable, say NA.

Is this animal/Are these animals part of any Restraining Order, Protective Order or any other legal case which could impact their safety at the PEI Humane Society?(Required)

Please explain. Please give as much detail as you're able to. If not applicable, say NA.

Does anyone else have legal ownership/claim of your animal(s)?(Required)

Please explain. Please give as much detail as you're able to. If not applicable, say NA.

If you are involved in a situation involving an abuser of you or the animal, please give a description of the person below:

Please include the person's name, description, age, height, weight, workplace, make, model, and colour of their vehicle, license plate number and any other identifying information you deem relevant. If you have a photograph of this person, please send it to the confidential shelter email: manager@peihumanesociety.com

Animal Intake Form

Your animals(') name(s)(Required)

Please include any aliases, nicknames or other names your animal(s) might answer to.

Species(Required)

Breed (Type)(Required)

Description/Unique Markings(Required)

Altered?(Required)

Has your pet been spayed or neutered? Yes or no?

Sex (Male, Female, Unknown)(Required)

Your pet's age and date of birth(Required)

Your Pet's Medical Information

You may need to contact your veterinarian for this information. While not having current vaccinations will not keep your animal( s) out of the PEI Humane Society’s Safe Haven program, it is important for us to have this information for the safety of your pet(s) and other animals.

Date of rabies vaccine

Date of distemper vaccine

For Dogs: Date of bordello (kennel cough) vaccine

For Cats: Has your cat ever been tested/vaccinated for FIV/FELV?

What flea and tick prevention do you use?

Current medications, known allergies or ailments

How are medications usually given? (ie: inside treats)

Other medical information

Feeding Instructions

Type of food (brand, formula, canned or kibble)

How much do you feed them and how often?

Treats

Additional information about feeding

Has your pet demonstrated any aggression around food?

Has your pet demonstrated any resource guarding?

Housing Information

During your animal's stay at the PEI Humane Society, they may be placed at the shelter itself, or they could be placed in foster care. This information will help us determine where they will be most comfortable.

What is your animal(s') housing situation?

Indoor/Outdoor

Where does your pet(s) sleep?

What is your pet(s) walk schedule?

Is your pet(s) house/litter trained?

Yes

Unknown

Is your pet(s) crate/kennel trained?

Yes

Unknown

Will your pet chew/scratch furniture, clothing, doors?

Yes

Unknown

Do you have other behavioural concerns?

Did you bring items that you would like kept with your pet? (favourite toy/bedding, etc)

My pet is...

Check all that apply

Good with dogs

Good with cats

Good with other animals

Good with children

Good with men

Good with women

To your knowledge, has the animal bitten or scratched anyone in the past 6 months?

If so, please explain.

How to apply for Safe Haven

Safe Haven Application Form

Owner's/Guardian's Information

Emergency Information

Other Important Information

Animal Intake Form

Your Pet's Medical Information

Feeding Instructions

Housing Information

PEI Humane Society

Mailing Address

Call Us

Emergencies

Hours