ACART Animal Intake Form ACART Animal Intake Form IntakeAnimal InformationIntake SummaryImportant Information & DisclosuresVeterinary CareVisitor Log Owner Contact Log & Departure INTAKE If you pre-registered click below to select your e-mail address to pre-populate the form and continue. Select E-mail Address Registration # * Deployment Event * type event name Adams Grove Fire (demo use only) Date * The date the animal(s) arrived to ACART shelter Time * 000102030405060708091011121314151617181920212223 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Time the animal arrived ACART Staff Member / Volunteer Click to Select Claire Alexander - AR38 John Baldwin - AR10 Cathy Baskin - AR11 Eileen Burwell - AR39 Kitten Chapman - AR32 Steve Collins - AR31 Mike Greene - AR13 Marsha Hamm - AR3 Cindy Sankovich - AR36 Carol Scarrone - AR5 Liz Touhey - AR40 Kathy Vicini - AR8 Other Volunteer - enter name ACART Staff Member / Volunteer What county do you reside in? * Amador Calaveras El Dorado Nevada Placer Other What county do you reside in? Arrival Status of Animals Dropped off by OWNER Dropped off by Other OWNER(S) INFORMATION Owner #1 Owner #1 - Contact Phone * Owner #1 - Alternate Phone Primary Email * Owner #1 - Driver's License Number or ID * State issued by: Would you like to add a second owner? Yes No Owner #2 Owner #2 - Contact Phone * Owner #2 - Alternate Phone Owner #2 - Driver's License Number or ID State issued by: Owner #2 - Email (if different) Enter Email Owner's Physical Address * Owner's Physical Address Owner's Physical Address Owner's Physical Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Owner's Mailing Address - if different than physical address Owner's Mailing Address - if different than physical address Owner's Mailing Address - if different than physical address Owner's Mailing Address - if different than physical address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Physical and Mailing Address are the same: Yes No Emergency Contact Person (if you are not reachable) Emergency Contact Person Emergency Contact Person First First Last Last Emergency Contact Phone Emergency Contact Person Email Enter Email OTHER PERSON DROP OFF - (Family, Friend, Neighbor, Rescuer) Drop Off Person * Drop Off Person First First Last Last Drop Off Person - Contact Phone * Drop Off Person - Email Drop Off Person - Address Drop Off Person - Address Drop Off Person - Address Drop Off Person - Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Drop Off Person - Driver's License or ID State issued by: Where was the animal found: (address / cross street / general area) * If you are human, leave this field blank. Next - Animal Description & Medical Info Print Start Over