Animal Surrender Form

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    Animal Information

    Species: DogCatOther
    Sex: MaleFemaleUnknown
    Color:
    Breed:
    Size/Weight:
    Age:
    Markings or Recognizable Traits:
    Rabies Tag Number:
    S/N:
    Microchip Number:
    Has the animal ever bitten anyone?
    Has the animal bitten anyone in the past 10 days?
    If so, please describe:
    Collar/leash/other items given with the animal:
    Other Information:
    Where did you get the animal?
    Why are you surrendering them?
    Vet records given with the animal:
    Any known medical issues?
    Are they on any medications?
    When was the last vet visit?
    Number of litters:

    Owner/Agent Information

    Name:
    Address:
    City:
    State:
    Zipcode:
    Driver's License State and Number:
    Phone:
    Email:

    Please help us get to know your dog so we can properly place him/her. Please be honest, as it will let us know what things we should work on with the dog.

    Training

    House/potty trained

    Kennel/crate trained

    Leash trained

    Rides in car

    Free roamer in house (can be left alone for extended time)

    Fence jumper

    Formal training

    Knows some commands (sit, stay, fetch, etc.)

    Comments:

    Social

    Is the dog or cat good with:

    Dogs

    Cats

    Farm animals

    Children under 10

    Strangers

    Comments:

    Personality

    Activeness: LowMediumHigh

    Affection Level: LowMediumHigh

    Timid or shy

    Nervous or skittish

    Dominant

    Excited urination

    Playful

    Comments:

    Living Conditions

    Inside: Free roamerKennel/crateDog doorOther

    If other:

    Outside: Tied upFenceDog houseOther

    If other:

    Behavior

    Barky

    Aggressive towards other animals/people

    Separation anxiety or other

    Aggressive over food/treats/toys

    Jumps up

    Growly

    Bites

    Digs

    Fear of loud noises

    Chases cars, people or other

    Protective of family, house or other

    Bitten, injured or killed another animal

    Bitten or injured a person

    Comments:

    Medical

    Up-to-date on vaccinations

    Spayed or neutered

    Other medical issues

    Medications

    Flea/tick prevention

    Heartworm prevention

    Vet records available

    Comments:

    Other Comments

    Relinquishing Receipt for Animals Surrendered to The Rescue Project by Owner

    I acknowledge that my signature on this document relinquishes all claims of ownership of the animal described above. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, suits, or otherwise against The Rescue Project with respect to this animal. I understand that The Rescue Project will not return this animal to me, once left in its care, under any circumstances, unless otherwise approved by The Rescue Project. I am also aware that the animal may be humanely euthanized if behavioral and/or medical problems render this animal unsuitable for adoption. I also hereby certify that the animal has or has not bitten a human or another animal within the past 10 days, as answered above. I hereby agree to release, indemnify and hold harmless The Rescue Project, its past, present and future officers, directors, agents and employees from and against any and all liability, claims, suits, actions, judgments, costs, fees, including reasonable attorney fees and damages caused by and/or arising out and/or in connection with this animal.

    Owner Name:

    Signature (use mouse):