Survey - 2013 Diamond Collar Hero Form

1.

Required fields are marked with an asterisk*.

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

Yes, I would like to receive e-mail from Oregon Humane Society

Yes, I would like to receive postal mail from Oregon Humane Society

Remember me. What's this? What's this?

*2.

Question - Required - Are you nominating an animal or a human? Animal
Human (jump to question #9)

3.

Question - Not Required - Name of animal you are nominating:

4.

Question - Not Required - Name of animal's owner:

5.

Question - Not Required - Owner's Address:

(Maximum response 255 chars, approx. 5 rows of text)

6.

Question - Not Required - Owner's Telephone:

*7.

Question - Required - Type of animal: Dog
Cat
Bird
Horse
Rabbit
Rodent
Other (please explain)

8.

Question - Not Required - Explanation

(Maximum response 255 chars, approx. 5 rows of text)

9.

Question - Not Required - If nominating a human, the name of the human hero:

(Maximum response 255 chars, approx. 5 rows of text)

10.

Question - Not Required - Address of the human hero:

(Maximum response 255 chars, approx. 5 rows of text)

11.

Question - Not Required - Telephone of the human hero:

12.

Question - Not Required - Your relationship to the human hero:

(Maximum response 255 chars, approx. 5 rows of text)

*13.

Question - Required - Are you and your nominated animal/human able to attend the event over lunch on February 23, 2013 in downtown Portland?

*14.

Question - Required - If nominating an animal, is the animal aggressive to people and/or other animals? (This will not disqualify you if the animal can be kenneled.)

*15.

Question - Required - Are you willing to speak to the media with your pet/human and do you understand that you can be asked to speak to the media on short notice?

*16.

Question - Required - Do you agree to allow the Oregon Humane Society to make a short video of you, the animal/human, and the animal's owners to show the night of the event and post on our Website? And, to take photos for release to the public when needed?

*17.

Question - Required - Should your pet or human win, are you (the owner) willing to sign a photo-and-video release for use locally or nationally?

*18.

Question - Required - Please describe in as much detail as possible what prompted you to nominate this hero. Questions to answer that may be relevant to your situation include: What did the hero do?; How do you feel regarding this hero's action; How do you know this animal (or where did you get the animal)?; How have the candidate's behavior, temperament and personality changed since the incident?; In the case of an animal's perseverance, what sets this animal apart from others who have suffered abuse or hardship? Please submit any photos, press clippings or other materials that support your nomination. Be sure to include the names and phone numbers of those who can provide additional information about this candidate's nomination. Mail additional materials to: Diamond Collar Awards Oregon Humane Society PO Box 11364 Portland, Oregon 97211