*JCAS Microchip Registration Form

First Name *
Last Name *
Cell Phone Number *
Email Address *
Address, City, Sate, Zip *
Emergency Contact Name *
Emergency Contact Number *
Please attach a picture of your pet here
Animal’s Name *
Animal’s Age *
Breed *
Male or Female *
Is the animal Spayed or Neutered? *
Color *
Does this pet require any medication for a medical condition? *	NoYes
If you answered yes to the question above, please explain in detail what condition and medication(s) are required.
I would like to register for the following date:
	Friday June 28 10am-2pm
By signing below I understand that upon check in I will be required to show proof of Jasper County residency via a valid Driver's License or Identification Card. I also understand in the event of rehoming, address change, death, or any changes to the animal's health that you will contact the company to update microchip information. I acknowledge that my dog must be vaccinated by a LICENSED VETERINARIAN yearly against Rabies. I.C. 35-46-3-1 Harboring a non-immunized dog Sec. 1. A person who knowingly or intentionally harbors a dog that is over the age of six (6) months and not immunized against rabies commits harboring a non-immunized dog, a Class C infraction. However, the offense is a Class B misdemeanor if the dog causes bodily injury by biting a person. *	Clear