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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
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Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
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Brazil
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Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
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Chad
Chile
China
Christmas Island
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Colombia
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Congo (Kinshasa)
Cook Islands
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Croatia
Cuba
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Cyprus
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Isle of Man
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Mali
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Mayotte
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Nigeria
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Pitcairn
Poland
Portugal
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Qatar
Reunion
Romania
Russia
Rwanda
São Tomé and Príncipe
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Saint Martin (French part)
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Samoa
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Slovenia
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Somalia
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Tunisia
Turkey
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Turks and Caicos Islands
Tuvalu
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Vatican
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Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Daytime Phone
Evening Phone
Email
Previous
Next
What kind of Assistance do you Require?
- Select -
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 Name
Pet's Age
- Select -
Under 3 Months
3 - 11 Months
1 - 5 Years
6 - 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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