Name * First Name Last Name Phone * (###) ### #### Please confirm phone number * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Type of animal being surrendered * Dog Cat Bird Small mammal Name of animal being surrendered * NOTE*** If you are surrendering more than one animal please fill out a separate form (###) ### #### Reason for surrendering * Is this animal your pet or did you find this animal? * This animal is my pet and I can no longer keep them I found this animal and am trying to help it Breed of animal being surrendered * (###) ### #### Gender of animal * Option 1 Option 2 Is this animal spayed/neutered? * Yes No Im not sure Animals weight * (###) ### #### Is this animal up to date on vaccinations? * If yes, we will request vet records. (###) ### #### Animals current age? * An estimate is okay (###) ### #### Animals age when acquired? * (###) ### #### Where did you get this animal from? * Please list names AND ages of everyone living in the same household as the animal. PLEASE INCLUDE CHILDREN * Please specify any other animals the animal lives with. * None Small dogs (under 25 lbs) Medium/large dogs (over 25 lbs) Cats Others (bird, ferret, hamster, rabbit...) Explain how this animal reacts to water/swimming * Explain how this animal reacts to baths * Explain how this animal reacts to dogs * Explain how this animal reacts to cats * Explain how this animal reacts to car rides * Please note any anxiety, car sickness, etc Explain how this animal reacts to strangers * IF SURRENDERING A DOG, explain how this animal reacts to leash walking Has this animal ever damaged anything when left unattended? If so, please describe Does this animal jump on people? * Yes No Only when excited I don't know Does this animal know any commands? * Sit, stay, come, down, fetch, leave it, etc. (###) ### #### IF SURRENDERING A DOG, is the dog crate trained? (###) ### #### How many hours daily is the animal left unattended? * (###) ### #### Please describe your household activity level * Please list your current vet office, name and phone number * Put N/A if you do not have a vet Is this animal currently taking monthly preventatives for flea, tick and heart worms? If yes, can you provide the brand * What is this animals exercise schedule? * Is this animal house trained? * Accidents? Where is the animal kept during the day? * Where is the animal kept at night? * Please describe this animals general temperment * Has this animal ever snapped or snarled at anyone? Please be honest. If yes, describe the situation * Has this animal ever shown signs of anxiety? Strangers, fireworks, cars, separation anxiety * Has this animal ever bit a human or other animal? If yes, please provide details * Please be honest. Lying puts our staff, fosters, families and other rescue animals in danger. Can you foster this animal while we home search? * Are you able to make a donation of minimum $100 to surrender this pet to our care? Yes I can do 100 Yes I can do even more No I am not able to Thank you!
