Shelterform

Shelter Form

Please use your Shelter Border Collie Form to fill in the information below. Use your Tab key to move to the next box; your Enter key to start a new line of text inside an answer box - i.e. when filling out your name, address, etc. (it will automatically move the rest of a sentence to the next line for you). Please be sure you have taken 2 pictures of each shelter border collie and emailed them to the Director, Dee Adamick, for identification and prior approval. Both pictures must show the dog in a standing position: 1 picture will be from the front face (looking slightly down upon the dog) showing full body; the 2nd picture will be from the side, showing full body & tail. Please be sure you have completed and submitted the interactive Evaluation for Relinquishment Form prior to completing this document . Both instruments become a permanent part of the dog's file. Fill in all empty boxes (write "none" if it doesn't apply) and Yes/No tabs. If you have questions or concerns, please email the Director, or the Foster Home Coordinator, Gina Moore.

REMEMBER.....we will accept mixes (except BC/Spaniel) ONLY if they have enough border collie markings, behaviors, and movements.

Today's Date:

Your name, full address, & telephone # (including area code):

Your email address:

Shelter name, full address, & telephone # (including area code):

Contact person (include title):

Dog's Name:

Date dog arrived in shelter:

Cage #:

Shelter Adoption #:

Shelter Control #:

Shelter ID #:

Was this dog picked up as a "stray":

Sex:

Age:

S/N?

Date Altered:

Spay/Neuter Certificate in hand? (required):

Color & full description (Blaze, chest, feet, tail, neck, etc:

Purebred or Mix (Describe, if mix):

Was this dog an Owner Relinquishment? If so, reason for relinquishing:

Vaccinations given by Shelter:

Rabies Certificate in hand?

Other medical care given by Shelter:

Is this dog Microchipped? (Ask them to scan it)

Brand Name:

Microchip Number:

Any other information on the dog?

BCR-MI ID#:

How you found out about this dog:

Shelter Fee:

Spay/Neuter Deposit (with contract):

Date required to S/N for Refund of Deposit:

Address for refund, if different from this Shelter address:

Date & results of last fecal exam:

Date & results of last HW test:

Did you take this dog to a Vet?

Date & Brand of HW Preventative given:

Is this dog coughing?

Don't forget to fill out a Reimbursement Form for any fees paid. Mail it along with all original receipts to:

                                           BCR-MI, INC.
                                          1606 Floral Ave.
                                   Jackson, MI   49202-2519

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