HWAH Short Term Care Agreement Your Contribution helps support HWAH.Our suggested value is $50.00 for the first dog and $30.00 for each additional dog. Any donation in excess of that amount is allowable under IRS guidelines for Charitable Contributions.Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Cell Phone*Email* How did you hear about us?Pet Information*Pet NameBreedBirthdayAgeWeightSexSpayed/Neutered Photo of dog* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB. Pet InformationPet NameBreedBirthdayAgeWeightSexSpayed/Neutered Photo of dog Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB. Pet InformationPet NameBreedBirthdayAgeWeightSexSpayed/Neutered Photo of dog Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB. Feeding instructions (Be specific for each dog)*Medications: Names, dosages, administration requirements (Be specific for each dog.)*Health Issues, limitations, diseases.(Be specific for each dog)*In the event of a health emergency, please name your emergency contact person that should be called to pick up your pet.* First Last Emergency Contact Cell Phone*Dog's Vet Name*Dog's Vet's Phone number*Special Needs (Check all that apply) Select All Cannot do stairs Separation anxiety Special feeding needs Needs special medications Physical limitations Food allergies Can play with other dogs Must go out alone I have requested that Sher Polvinale/HWAH care for my pet(s) while I am away* Yes No I understand that Sher Polvinale/HWAH will provide services in a reliable, caring and trustworthy manner and do everything possible to keep my pet(s) safe and secure and healthy while the pet(s) is in their care. The Owner agrees that life is full of surprises and promises in consideration of these services and as an express condition thereof to expressly waive and relinquish any and all claims against Sher Polvinale/HWAH except those arising from negligence or willful misconduct on the part of Sher Polvinale/HWAH.*Please Initial AboveI understand that if my pet interacts with other pets at the Sanctuary, he or she could be bitten or otherwise injured. I agree that if my pet interacts with others, I will not hold Sher Polvinale /HWAH liable if a bite or other injury occurs.*Please initial aboveI understand that if my dog is allowed to run in the fenced yards, there is a possibility that my pet may jump the fence. The Owner agrees that it will not hold Sher Polvinale /HWAH liable if the pet jumps the fence.*Please initial abovePLEASE NOTE: House with a Heart reserves the right to turn away any pet that is in poor condition at the time of drop off. This includes: pets who are in obvious pain, have not been seen by a Vet and do not have medication to keep them comfortable. Pets who are matted and dirty and in need of grooming.* I agree I disagree If necessary: Do we have permission to bathe your dog?* Yes No Important Medical Emergency InformationShould medical attention be necessary, every attempt will be made to notify Owner regarding such situation. If Owner is not reachable and time is of the essence, the emergency contact person specified by Owner will be contacted. However, if the emergency contact is also unavailable, the Owner authorizes Sher Polvinale/HWAH to approve medical and/or emergency treatment (excluding euthanasia) as recommended by a veterinarian. The Owner releases Sher Polvinale/HWAH from all liabilities related to transportation, treatment and expense.*Please Initial aboveIn the case of a medical emergency, do you want your pet to be held at the Vet and on life support until your return?* Yes No Do you want your pet to be euthanized if he/she is suffering?* Yes No In the event of your pet's death, do you want he/she to be cremated and ashes returned?* Yes No In the event of your pet's death, do you want a pawprint done if available?* Yes No Additional comments you want us to know.I have reviewed this agreement in its entirety. I understand that HWAH is not responsible for unexpected circumstances beyond their control which may cause a change in their ability to provide short term stay care for my pet. I have made the appropriate choices. The information provided by me is complete and accurate and I agree to all its terms and conditions as set out above. Please put your name and date below.* First Last Date MM slash DD slash YYYY Date format: MM/DD/YYYY Δ
