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:
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:
Date Signed:

Signature (use mouse):