Palm Beach County Logo, link to home page
 
Public Safety  Divisions Hurricane Preparedness PBC Departments

 

Pet Friendly Shelter Form

 
Registration Date:
Owner's Information:
Last Name:
First Name:
Address:
Apt/Suite:
City:
State: Florida
Zip Code:
Home Phone:
Cell Phone:
E-Mail:
Use internet-style format (e.g. abc@abc.com)
Date of Birth:
Driver's License Number:
Evacuation Zone: Yes No Unknown
Number of immediate family members planning on coming to the shelter:
Please enter only numbers
Emergency Contact Information: (This should be someone who does not live with you but is authorized to pick up your pet.)
Last Name:
First Name:
Address:
Apt/Suite:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Please provide the following information: Proof of residency (copy of utility bill).
A signed copy of the Waiver form Adobe PDF Document.
Pet Information for Pet 1:
Type of Pet: Dog/Puppy Cat/Kitten
Pet's Name:
Gender: Male Female
Neutered/Spayed: Yes No
Breed:
Color:
Age:
Weight: lbs.
Rabies Tag # and Year:
Microchip #:
Flea/Tick Medication:
Date Flea/Tick Medication Last Administered (ie: Frontline):
Pet Information for Pet 2:
Type of Pet: Dog/Puppy Cat/Kitten
Pet's Name:
Gender: Male Female
Neutered/Spayed: Yes No
Breed:
Color:
Age:
Weight: lbs.
Rabies Tag # and Year:
Microchip #:
Flea/Tick Medication:
Date Flea/Tick Medication Last Administered (ie: Frontline):
Pet Information for Pet 3:
Type of Pet: Dog/Puppy Cat/Kitten
Pet's Name:
Gender: Male Female
Neutered/Spayed: Yes No
Breed:
Color:
Age:
Weight: lbs.
Rabies Tag # and Year:
Microchip #:
Flea/Tick Medication:
Date Flea/Tick Medication Last Administered (ie: Frontline):