BratPack Rescue, Inc.

501(c)(3) tax exempt charitable organization

PO Box 807 - Mt. Dora, FL 32756
Ph. (352) 577-0036 - Fax (775) 923-8406

Bichon Frise and Small Breed Rescue

~Caring For Each Of Them As If There Is Only One Of Them~

An Independent Bichon Rescue Adhering to BFCA

"Best Practices/Guidelines"


Bichon Frise in Need of Rescue

Before you fill out this form, would you like to speak to a counselor for help in solving a
behavior problem with your pet? Have you considered a belly band for housebreaking
problems? (If you don't know what this is, it's OK - we will explain it to you!)
Together, we may be able to find a way to help you keep your dog.
Call Karen at (954) 298-5945 or email her at bichonrescuefl@aol.com


Please provide the following information concerning a Bichon Frise that you need to give-up to a
Rescue Volunteer, or that needs to be rescued by a Rescue Volunteer. For efficiency purposes,
please complete as much of the information as you can and be as accurate as you can.

Date:
	INFORMATION ABOUT PERSON SUBMITTING THIS
Your Name:
If applicable, you represent:
Email Address:
Daytime Phone (include area code):
Evening Phone (include area code):
Your Street Address:
City, State, Zip:
OWNER / GUARDIAN INFORMATION, IF DIFFERENT
Owner Name:
Owner Email:
Owner Daytime Phone (include area code):
Owner Evening Phone (include area code):
Owner Street Address:
Owner City, State, Zip:

	BICHON INFORMATION
Geographic location of bichon (City, State):
Bichon's name (or shelter ID):
Bichon's sex:
Is bichon neutered:
	If not, would you be willing to make a donation to cover the cost of the neuter, or have the procedure done by your vet:
Bichon's age:	If estimate, indicate "est."
Bichon's weight:
	Bichon is being maintained at (Owner's Home, Shelter, Foster Home):
Has the bichon ever bitten anyone:
	Describe in detail the number of times and circumstances (dates occurred, number of times, adult, child, family member or stranger, dog provoked, dog in a crate or backed up in a corner, dog ill, etc.):
Has bichon recently been tested for heartworms:
Heartworm test results (negative, positive):
Date of heartworm test (MM/DD/YY):
Can you provide proof of heartworm test:
	BICHON HEALTH OR HEALTHCARE REQUIREMENTS
	Describe in detail whether the dog is known to be or appears to be healthy, OR if there are any known or apparent health problems (heartworm positive/negative, kennel cough, parvovirus, blindness, cataracts, deafness, paralysis, ringworm, demodectic mange, ear mites, tape worms, hypothyroidism, cushing's disease, autoimmune diseases, cancers, enlarged heart or heart diseases, pancreatitus, gastritis, seizures/epilepsy, patella luxation, hip dysplasia, ruptured discs, bladder stones, severe gum disease, severe inhalant or flea allergies, etc.,):
	Also, describe in detail any known or apparent short term or long term health care requirements/costs (medications required, frequency and estimated costs if known, treatments, surgeries required and costs if known, special foods and diets, etc.,):
	BICHON'S PHYSICAL CHARACTERISTICS/APPEARANCE
	Describe in detail the Bichon's current physical condition and characteristics (missing an eye, missing a limb, extremely dirty and/or matted and needs shaving/bath, already shaved and bathed, missing hair due to trauma or disease, rashes; Or in fairly good to great condition: not matted, basically clean and taken care of, etc.):
Is bichon housebroken:
Describe any details:
Has the bichon lived with or been around/exposed to children:
	Describe any details (number of children, ages, sex, lived with or exposed, frequency, good or bad experiences with children, etc., ):
Has the Bichon lived with or been around/exposed to other animals?
	Describe any details (types of animals, number, sex, lived with or exposed, frequency, good or bad experiences with which animals, etc.,):
	BICHON'S BEHAVIOR/TEMPERAMENT
	Describe in detail any personality or behavioral characteristics (aggressive, shy, quiet, barks excessively, good or bad with strangers, prefers male or female humans, etc., ) :
Reason why Bichon has to be placed with Rescue:
Urgency of Rescue:
	How long can the dog be maintained until a rescue volunteer needs to take possession?:
	ADDITIONAL INFORMATION
How long has current Owner had/maintained this Bichon?
	How and Where was this Bichon obtained ? (purchased, gift, adopted; From whom: Breeder, Shelter or Store's name, address, city, state, phone number, etc):
Is the Bichon registered (AKC, CKC, etc.,)?
	Can the registration papers be produced and provided to Rescue Volunteer?
Is the Bichon Microchipped or Tattooed?
Is there a Crate in fairly good condition that can be given with the Bichon?
What Types of food or Brands was the Bichon fed?
Does the bichon have a current Rabies Vaccination:
Date Rabies Last Given (MM/DD/YY):
Can you provide proof of Rabies Vaccination:
Does the bichon have current DHPP (or Other Combination) Vaccination:
Date DHPP Last Given (MM/DD/YY):
Type of Combo Vaccination, what included:
Can you provide proof of DHPP Vaccination:
Does the bichon have current Bordetella Vaccination?
Date Bordetella Last Given (MM/DD/YY):
Can you provide proof of Bordetella Vaccination:
Is the Bichon Currently on Heartworm Preventative ?:
Date Preventative Last Given (MM/DD/YY):
Type/Brand of Preventative, Frequency:
Veterinarian Name:
Veterinarian Hospital:
Veterinarian Phone (include area code):
Veterinarian Fax:
Veterinarian Street Address:
City, State, Zip:
Additional comments:

BY CLICKING "SUBMIT", I ACKNOWLEDGE THAT ALL THE INFORMATION CONTAINED ON THIS APPLICATION FORM IS TRUE AND CORRECT. I UNDERSTAND THAT ANY MISREPRESENTATION MAY RESULT IN THE REMOVAL OF THE ADOPTED DOG FROM MY HOME BY BRATPACK RESCUE.