Municipality of Jasper - Pet Rescue Form

Pet Rescue Form

<form-template>
	<fields>
		<field type="header" subtype="h1" label="If you have evacuated, and your pet(s) are still at your residence and you require assistance for them, please fill out this form. " class="header"></field>
		<field type="header" subtype="h3" label="Please provide as much information as possible. We are collecting information to help facilitate emergency assistance to the best of our abilities with the local authority and animal rescue organizations. Successful pet rescue is not guaranteed and will depend on the resources available, and the specifics of the emergency. " class="header"></field>
		<field type="header" subtype="h3" label="Owner Information: " class="header"></field>
		<field type="text" subtype="text" required="true" label="Name (first, last): " class="form-control text-input" name="text-1660256018955"></field>
		<field type="text" subtype="text" required="true" label="Address:" class="form-control text-input" name="text-1660256051066"></field>
		<field type="text" subtype="text" required="true" label="Phone Number:" class="form-control text-input" name="text-1660256067930"></field>
		<field type="text" subtype="text" required="true" label="Email: " class="form-control text-input" name="text-1660256090466"></field>
		<field type="text" subtype="text" required="true" label="Owner's Current Location (town or city evacuated to)" class="form-control text-input" name="text-1660256120218"></field>
		<field type="header" subtype="h3" label="Animal Information" class="header"></field>
		<field type="checkbox-group" label="Is animal located at address listed under 'owner information'?" class="checkbox-group" name="checkbox-group-1660256246321">
			<option value="option-1" selected="true">Yes</option>
			<option value="option-2">No </option>
		</field>
		<field type="text" subtype="text" label="If no, please provide address" class="form-control text-input" name="text-1660321006987"></field>
		<field type="select" label="Type of animal" class="form-control select" name="select-1660321050690">
			<option value="option-1" selected="true">Dog</option>
			<option value="option-2">Cat</option>
			<option>Small Animal</option>
			<option>Reptile/Exotic</option>
			<option>Bird</option>
			<option>Other</option>
		</field>
		<field type="checkbox-group" required="true" label="location within the home (check all that apply)" class="checkbox-group" name="checkbox-group-1660321144586">
			<option value="option-1" selected="true">has full access to residence </option>
			<option value="option-2">Main level </option>
			<option>Upper level </option>
			<option>Basement</option>
			<option>Animal in kennel </option>
			<option>Unsure </option>
			<option>Other </option>
		</field>
		<field type="text" subtype="text" required="true" label="Animal's Name " class="form-control text-input" name="text-1660321275968"></field>
		<field type="text" subtype="text" required="true" label="Species " class="form-control text-input" name="text-1660321289287"></field>
		<field type="text" subtype="text" required="true" label="Size" class="form-control text-input" name="text-1660321317549"></field>
		<field type="text" subtype="text" label="Breed" class="form-control text-input" name="text-1660321330725"></field>
		<field type="text" subtype="text" label="Age" class="form-control text-input" name="text-1660321341973"></field>
		<field type="text" subtype="text" label="Description (colour, special markings, etc.) " class="form-control text-input" name="text-1660321354357"></field>
		<field type="checkbox-group" label="Please check any important additional information about your animal (check all that apply)" class="checkbox-group" name="checkbox-group-1660321404155">
			<option value="option-1" selected="true">Animal has a health condition</option>
			<option value="option-2">Animal requires medication</option>
			<option>Animal is aggressive and/ or is a bite risk </option>
			<option>Animal has other behavioral issues </option>
			<option>Other </option>
		</field>
		<field type="textarea" label="Please provide details for any of the ticked boxes above:" class="form-control text-area" name="textarea-1660321510464"></field>
		<field type="header" subtype="h3" label="CONSENT If necessary for potential rescue efforts, please provide the following information to allow access to your property and residence to assist your animals in need. This information will only be used on a need-to-know basis." class="header"></field>
		<field type="checkbox-group" required="true" label="Ease of access: Check all that apply" class="checkbox-group" name="checkbox-group-1660321619142">
			<option value="option-1" selected="true">Hidden House Key </option>
			<option value="option-2">Door Code </option>
			<option>Garage Code </option>
			<option>Other </option>
		</field>
		<field type="textarea" required="true" label="Further instructions relating to ticked boxes above:" class="form-control text-area" name="textarea-1660321678404"></field>
		<field type="textarea" required="true" label="Any other additional information or comments that would be helpful in assisting animals:" class="form-control text-area" name="textarea-1660321719892"></field>
		<field type="checkbox" required="true" label="I give permission to the Municipality of Jasper to enter my home by any means necessary in order to rescue my pet. " class="checkbox" name="checkbox-1722098093497"></field>
		<field type="textarea" required="true" label="I understand that I have provided this information to request emergency assistance for my animal(s) currently in my residence. Type your name in this box in lieu of signature:" class="form-control text-area" name="textarea-1660321760260"></field>
		<field type="textarea" label="Text Area" class="form-control text-area" name="textarea-1722096078335"></field>
	</fields>
</form-template>

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