Intake and Release Form
Please complete all sections to accurately document the intake and release process.
Full Name of Individual/Entity
*
First Name
Last Name
Date of Intake
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Intake
*
Please Select
Person
Animal
Item/Asset
Other
Description of Individual/Item/Animal
*
Condition at Intake
*
Please Select
Excellent
Good
Fair
Poor
Other
Reason for Intake
Responsible Staff Member (Intake)
*
First Name
Last Name
Date of Release
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Condition at Release
*
Please Select
Excellent
Good
Fair
Poor
Other
Recipient Name (Person/Organization Receiving)
*
First Name
Last Name
Release Method
*
Please Select
In Person
Shipped/Delivered
Transferred
Other
Notes or Special Instructions
Signature of Responsible Staff (Release)
*
Submit
Submit
Should be Empty: