Animal Evacuation /SIP Request Form

ANIMAL EVACUATION / SHELTER-IN-PLACE REQUEST

Small Companion Pets, Livestock, Poultry/Fowl & Equine
Date*

MonthDayYear
Hour MinutesAM/PM Option
Incident Name:*
(Ex. Creek Fire, Fresno Floods)
Are You The Animal Owner?*

YesNo
What are you requesting for your animals?*

EvacuationShelter-in-Place Care

Animal Owner Information

Please answer the questions to the best of your ability. The fields with the * are required.
Last Name*
First Name*
Home Street Address*
City*
Zipcode*
E-mail Address
Mobile Phone Number (24/7)*
Are your animals at your home address?*

YesNo
If not, what is the property address where they are located?

Non-Owner Reporting Person

(Family member, neighbor, friend, emergency responder, etc.)
First Name (Reporting)
Last Name (Reporting)
What Is Your Relationship To Animal Owner?
(ex. family, friend, neighbor, etc.)
Mobile Phone Number (Reporting)
Email (Reporting)
Have You Made Contact With Owner?

YesNo
Are You An Emergency Responder?

YesNo
If Yes what agency/ company?
(ex. Fresno County Sheriff's Office, Cal Fire, PG & E

SMALL COMPANION PETS (Dogs, Cats, Guinea Pigs, Reptiles, etc).

Additional Information On the Small Companion Pets. If being sheltered-in-place, provide care instructions.
(ex. if pets need medications or special diet food - give location)

Permission To Evacuate Animals

Liability Waiver Required
The animal owner/agent listed hereby requests emergency animal services from the Central California Animal Disaster Team (CCADT) for the animal(s) described on this form. The animal owner/agent hereby releases and holds harmless the CCADT and any emergency response agencies from any and all liability from the evacuation, care, sheltering, and/or sustained injury and/or death of the animal(s) during and following the incident.

It is the responsibility of the animal owner/agent to keep CCADT informed of where the animal(s) owner or agent can be contacted during and following the emergency/disaster event. Please contact CCADT at evac@ccadt.org if you have questions or text to (888) 333-EVAC (3822
I have read the above information before signing and fully understand the content, meaning and impact. Please click to agree or disagree. If you click Disagree, we will be unable to evacuate or provide shelter-in-place care for your animals(s)*

I Agree to the aboveI Disagree to the above
Signature*
Should be Empty:

ANIMAL EVACUATION / SHELTER-IN-PLACE REQUEST