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Selecting a Substitute Pet Guardian

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In the event of an emergency and I am unable to make a decision for my pet(s), or to be located, I give permission for ________________________________ and _________________________________  to enter my home at: _____________________________________________and transport my pet(s): ___________________________________________  _______________________________  (use opposite side of paper for additional pet names) for the purpose of temporarily caring for my pets and seeking emergency medical treatment and/or placement in temporary emergency sheltering.

_________________________________                  __________________________________   date: _______

(signature)                                                                    (Print Name)

Designated Pet Guardian (designated by pet owner): ___________________________________________________

Address: ______________________________________________________________________________________

Telephone: (Home): ________________________ (Work): _________________________ (Cell): ______________

Witness: ________________________________  Date: _________________

Pet/breed(s) name(s):_____________________________________________________________________________

______________________________________________________________________________________________

My pet does not have any history of aggression ___________ (initial & date)

My pet does have a history of aggression, please take the following precautions: ___________________
___________________________________________________________________________

___________________________________________________________________________

By signing below I understand that ___________________________________will do everything possible to provide my animal with a safe and secure location while I am unable to do so. I understand that while all attempts will be made to use my designated veterinarian and/or to place my pet(s) in the closest shelter/boarding facility, that it may not be possible to do so, due to the scope of the emergency. I also agree not to hold my substite pet caregivers liable for any damages that occur as a result of a good faith effort to provide care.

Pet(s) Owner: ______________________________________________________ Date: _________________

                                                (Signature)