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Pet Owner Disaster Planning Worksheet
Emergency Pre-Planning Worksheet
(make a copy for your designated pet guardian and attach copy of pet’s current vaccination record)
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Owner Name: ___________________________________________________________________ Date: ____________________
Address: _________________________________________ P.O. Box: ________________ email: ________________________
City: ____________________________________ County: _______________________ Zip code: ______________________
Home Phone: _____________________ Work: _____________________ ext. ________ Cell/Pager: _______________________
Pet Type: __________________________________________ Name: ____________________________ Sex: Male Female
Breed: ________________________________ Color/Markings: ____________________________________________________
If frightened, or not feeling well, my pet (indicate behaviors pet may exhibit or places pet might hide) :______________________
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If I am unable to be located, what I want an emergency response volunteer to know about my pet: Fears, Loves, Temperament, How they get along with other animals and anything else you think we should know:__________________________________________
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Additional Information about my pet that I might need to have with me, or need to have knowledge of:
Spayed/Neutered Copy of current vaccination records attached Current Medication List w/instructions attached
Heartworm Preventative Flea Treatment Used: ____________________________ Microchipped
Allergies: _______________________________________________ Special Diet: ___________________________________
Veterinarian: _____________________________________________________________ Phone: _______________________
WHO IS THE CLOSEST PERSON(S) WHO WOULD COME TO MY HOUSE AND PICK UP MY PETS?
Name: ____________________________________________ Address: _________________________________________
City: ___________________________ State: _____________ Phone: (Home)_________________(Work)______________
Location they would take my pet to:___________________________________ or: ________________________________
Name: ____________________________________________ Address: _________________________________________
City: ___________________________ State: _____________ Phone: (Home)_________________(Work)______________
Location they would take my pet to:___________________________________ or: ________________________________
What are other options for my pet(s) to stay with me following an emergency?
Hotel: ____________________________________________ Phone: _________________________________________
Hotel: ____________________________________________ Phone: _________________________________________
Friend: ___________________________________________ Phone: _________________________________________
Other: ____________________________________________ Phone: _________________________________________
MY PREPARATION CHECKLIST
I have prepared my pet in the event of a disaster by: Always bringing my pet indoors when threatening weather or conditions exist Having a pre-designated safe haven located within my home, with adequate water, food, and medications for myself, family, & pets for 3 days Having a stake and tie out cable that I could secure my pet with, if needed Having a portable crate, correctly sized for my pet Consider Tattooing or Microchipping my pet Making sure my pet wears a collar with identification at all times Having a correctly sized heavy duty leash or halter readily available Having a prepared emergency kit customized for my pet Keeping my pet’s vaccinations current Having a current photo of myself with my pet Keeping the names and phone numbers of those who would pick up my pets with me at all times By knowing what hotels in my area allow pets
ALWAYS TAKE YOUR PET WITH YOU IF YOU MUST EVACUATE – SOMEONE WILL HELP YOU FIND APPROPRIATE SHELTER FOR BOTH YOU, AND FOR YOUR PET
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Permission to seek Sheltering and Veterinary Care
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 any representative thereof, to transport my pet(s) for the purpose of 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: ___________________
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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 understand that in an emergency, the Good Samaritan Act is in force and that ________________________ and/or any emergency shelter or foster home cannot be held liable for any damages that occur as a result of a good faith effort to provide care.
Pet(s) Owner: ______________________________________________________ Date: _________________
(Signature)
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