Crisis Boarding Program Applicant Information Roice-Hurst Humane Society (RHHS) strives to keep pets with their families whenever possible, recognizing how important pets are to overall well-being. Please read the following carefully and fill out the application to best of your ability. Thank you for your commitment to caring for your pet(s)!By clicking YES, Applicant understands that the purpose of this program is to provide temporary care for pets whose owners otherwise would not be able to afford or find temporary care on their own or pay for boarding costs.* YES By clicking YES, Applicant understands RHHS cannot guarantee boarding the same day this application is filled out.* YES By clicking YES, Applicant understands acceptance into this program is based on the applicant’s long-term ability to care for their pet(s).* YES By clicking YES, Applicant understands a weekly fee may be required to help cover the cost of boarding.* YES By clicking YES, Applicant understands that RHHS cannot guarantee boarding assistance.* YES By clicking YES, Applicant understands RHHS is only able to assist for up to 30 days, and duration may be limited based on availability.* YES By clicking YES, Applicant understands that RHHS partner with local boarding kennels, and therefore the animals are housed at a boarding kennel and not at Roice-Hurst Humane Society.* YES By clicking YES, • Applicant understands animals are not housed at Roice-Hurst Humane Society.* YES By clicking YES, If Applicant needs confidential placement for animals, applicant will discuss this with RHHS staff immediately. YES Name* 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 Phone*Email* How did you hear about this program?*How long do you need care?*Please explain the reason you need assistance and what is your plan to reunite with your pet(s).*Pet 1* Cat Dog Pet 1 - Name, Age, Sex, Breed (if known), Color(s) and any distinguishing marks.*Pet 1 - Spayed/Neutered* Yes No Unknown Pet 1 - Please check all vaccinations that your pet(s) has received within the last three years: *Please note vaccinations are required for boarding.* Select All Rabies Distemper/Parvo Bordetella Other None Pet 1 gets along with:* Select All Cats Dogs Children Adults Pet 1 - Has this pet bit a person or other animal? If yes, please explain the situation.*Pet 1 - Please list any medical or behavior concerns, allergies, special dietary needs, and current medications.*Pet 2 Cat Dog Pet 2 - Name, Age, Sex, Breed (if known), Color(s) and any distinguishing marks.Pet 2 - Spayed/Neutered Yes No Unknown Pet 2 - Please check all vaccinations that your pet(s) has received within the last three years: *Please note vaccinations are required for boarding. Select All Rabies Distemper/Parvo Bordetella Other None Pet 2 gets along with: Select All Cats Dogs Children Adults Pet 2 - Has this pet bit a person or other animal? If yes, please explain the situation.Pet 2 - Please list any medical or behavior concerns, allergies, special dietary needs, and current medications.Pet 3 Cat Dog Pet 3 - Name, Age, Sex, Breed (if known), Color(s) and any distinguishing marks.Pet 3 - Spayed/Neutered Yes No Unknown Pet 3 - Please check all vaccinations that your pet(s) has received within the last three years: *Please note vaccinations are required for boarding. Select All Rabies Distemper/Parvo Bordetella Other None Pet 3 gets along with: Select All Cats Dogs Children Adults Pet 3 - Has this pet bit a person or other animal? If yes, please explain the situation.Pet 3 - Please list any medical or behavior concerns, allergies, special dietary needs, and current medications.FinancialApplicants must demonstrate their need for assistance by providing most recent paystub, SSI/SSDI letter, medical bill or SNAP card. If participant is referred by a human service agency, applicant may skip this section. Total Monthly Income*Total Household Income* Do you receive assistance from the following entities? Check all the apply.* Select All SNAP Social Security Administration free or reduced lunch program TANF Housing Assistance Medicaid/Medicare program None Are you a military veteran?* Yes No Excluding yourself, please list all household members, along with their age, that you help support.*Are you currently working with the Housing Authority, Catholic Outreach, Pathways, Veterans Administration, or any other housing or social services agency? Please list all that are applicable.*Applicant, being of sound mind, provide consent for Roice-Hurst Humane Society to contact the listed housing agencies, or social service professionals provided above. Please note, we will ask your permission before we contact.* Consent* I HEREBY WARRANT THAT I (A) AM AT LEAST EIGHTEEN (18) YEARS OF AGE AND THE AGE OF MAJORITY IN THE STATE IN WHICH I RESIDE. I WARRANT and AFRIM THAT I HAVE ANSWERED THE ABOVE QUESTIONS TRUTHFULLY AND TO THE BEST OF MY KNOWLEDGE.CAPTCHANext StepsYou can expect a RHHS staff member to contact you within 48 hours (weekends excluded). Please begin to gather your income verification documents and vaccination records. Thank you!