This form is to be used by the person who physically accepts this dog in to BROOD. Either submit online (preferred) or print and send to the address at the bottom of the form. FOSTER FAMILIES should fill out a FOSTER DOG REPORT instead of this form.
Required fields are indicated in bold with *
BASIC DOG INFORMATION
1. Dog Name:
2. Dog's Age (if known) OR Unknown, but probably Young Middle Senior
3. Dog's Gender: Male Female
4. a) Primary color: Brown Black White Red
4. b) Pattern (purebred bassets are listed as tri-color or red & white, even if the "red" looks more brown or tan): Tri-Color Red & White Other (use only for mixes)
If OTHER, please describe:
5. Other Comments. (if dog is no longer in your possession or will be transferred soon, please include contact name, email and phone number):
Volunteer Name:*
Phone Number:* Email:*
Shelter or ORD Name:*
Shelter or ORD Street Address:*
Shelter or ORD City:* State:* Zip Code:
Shelter or ORD Phone:*
IMPORTANT: You must click on the "SUBMIT Preliminary Intake Report" button to complete this form!
BROOD thanks you for taking the time to evaluate this incoming basset. Your evaluation is critical to ensure proper placement in a foster and permanent home.
Mailing Address: BROOD at 3445 Seminole Trail, Box 248, Charlottesville, VA 22911