Wildlife Intake Form Wildlife Intake Form Please remember that our rehabilitators are also volunteers and you are bringing your animal(s) into their homes. Kindness, mindfulness and flexibility are appreciated. If you would like to support the individual intaking your animal(s), or all of our rehabilitators, please donate directly to our organization. Intake FormDrop-off DateBrought-in ByPhone NumberEmailAddressAddress Line 1Address Line 2CityStateZip CodeHow did you hear about us? I've brought you wildlife before I found you via social media/internet Referred by someoneBy whom- Select -A friend or neighborWildlife Rescue League directly gave me your nameWildlife Rescue League sent me to the Dept Wildlife Resources directory of rehabilitatorsVeterinarianAnimal ControlTrapperAnother RehabilitatorOtherwhich media- Select -ReWild website/googleFacebookNextdoorVA Dept. of Wildlife ResourcesOtherPlease provide their name (If Animal Control, provide county)Other InfoPlease know that we do not participate with nor receive funding from the Wildlife Rescue League. If you wish to donate to the rehabilitator directly caring for your animal(s), please do so through our ReWild NoVa website or via the button at the end of this form.Accepting RehabilitatorLaura, HaymarketClare, Fairfax StationL'mae, UppervilleNicole, RestonRachael, McLeanItem 4Item 3Item 2Item 1Species- Select -BatBeaverBirdChipmunkCottontail (Bunny)FawnFlying SquirrelFoxFrogGroundhogMouseOpossumRaccoonSkunkSnakeSquirrelTurtleOtherText InputNOTICE: Virginia defines a as a Rabies-Vectored species. Please answer the following questions with as much detail as possible.Did the the animal bite, scratch or lick anyone? Yes NoPlease describe what happenedList name, address, and phone number of person(s) bitten, scratched or lickedWas the animal hand-fed? Yes NoHas anyone handled the animal without gloves? Yes NoList name, address, and phone number of person(s) who handled without glovesDid the animal have any contact with a dog or a cat? Yes NoPlease describe the interactionIs the dog or cat referred above current on rabies vaccination? Yes NoNumber of AnimalsApproximate Age of Animals Newborn Juvenile AdultWhere was it foundCircumstancesCondition (describe)Date First SeenDate CapturedDid you feed the animal? Yes NoWhat/how/when did you feed the animal?Did you help it in any other way?All wildlife care is on a volunteer basis. If you care to leave a donation below to help cover our expenses, it would be appreciate and will be used to care for your (s). Donate In Support Don't worry! The button above opens a new window so you don't lose your place!By submitting this form, you agree to relinquish all claim to, and responsibility for, the above described animal(s) upon delivery to a ReWild NoVa rehabilitator.Submit Form
