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GRFF Assistance Intake Form
Date
First Name
Last Name
Address
Address Line 1
Address Line 2
City
State
Zip Code
Country
Select Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belau
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
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Kuwait
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Laos
Latvia
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Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
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Mauritius
Mayotte
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Montserrat
Morocco
Mozambique
Myanmar
Namibia
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Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
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Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
São Tomé and Príncipe
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (Dutch part)
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom (UK)
United States (US)
United States (US) Minor Outlying Islands
United States (US) Virgin Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Daytime Phone
Evening Phone
Email
Previous
Next
What kind of Assistance do you Require?
- Select -
Relinquish my dog
To Get a Spay/Neuter Voucher
To Get Help With a Problem
Other
Please explain
Do you Own or Rent Your Home?
Own
Rent
No Fixed Address
Other
Prefer Not to Answer
Do You Share a Home With People Who Aren't Part of Your Immediate Family?
Yes
No
Prefer Not to Answer
Gender Identity
- Select -
Woman
Man
Transgender
Non-Binary/Non-Conforming
Prefer not to Respond
Ethnicity
- Select -
Hispanic
Black / African American
White
Asian
Native American
Native Hawaiian / Pacific Islander
Multi-ethnic
Prefer Not to Answer
Primary Language Spoken in the Home
- Select -
English
Spanish
Bilingual - Spanish / English
Other
Your Age
- Select -
18 - 29
30 - 49
50 - 69
70 or older
Prefer not to Answer
Approximate Total Gross (Before Taxes) Annual Household Income
- Select -
Less than $10,000
$10,000 ~ $19,000
$20,000 ~ $29,000
$30,000 ~ $39,000
$40,000 ~ $49,000
$50,000 ~ $59,000
$60,000+
Prefer not to Answer
Do You Receive Public Assistance
Yes
No
Prefer not to Answer
Previous
Next
Questions About Your Pet
Dog or Cat?
Dog
Cat
Other
Pet's Age
- Select -
Under 3 Months
3 ~ 11 Months
1 ~ 10 Years
11+ Years
Don't Know
Pet's Reproductive Status
- Select -
Male
Neutered Male
Female
Spayed Female
Pregnant Female
Has the Pet Ever Been to the Vet?
Yes
No
Don't Know
Has the Pet Ever Had a Rabies Vaccine?
Yes
No
Don't Know
Has the Pet Been Micro Chipped?
Yes
No
Don't Know
Your Pet's Physical Condition
- Select -
Extremely Thin
Thin
Slightly Underweight
Healthy Weight
Slightly Overweight
Overweight
Extremely Overweight
How did you get this Pet?
- Select -
Pet Store
Breeder
Online / Newspaper
Friend / Family / Neighbor
Shelter / Rescue
Litter from another dog in your home
Other
Where does your pet normally live?
- Select -
Indoors Only
Outdoors Only
Indoor / Outdoor
Other
How many other pets live in your home?
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