Animal Surrender Form 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: Driver's License State and Number: Phone: 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: Date Signed: Signature (use mouse):
