Heart Animal Rescue - Surrender Form

Legal Name

Street Address

City, State, Zip Code

Home Phone/Cell Phone

Email

Animal(s) Name

Breed

Age

Sex

Male

Female

Spayed/Neutered

Yes

No

Age obtained and from where?

Vet Clinic name/address/phone number

Is animal current on vaccinations?

Yes

No *If no is marked, please explain in next question

If "No" to current vaccinations, please explain.

Does this animal have any medical problems?

Yes *If marked, please answer following question

No

If 'Yes' to above medical problems, please explain along with any medications they are on.

Please sign your name to give Heart Animal Rescue permission to call and verify animal's vet records. You may need to contact your vet clinic to release information as some clinics require this.

Housebroken?

Dog is housebroken

Dog is not housebroken

Cat is litter box trained

Cat is not litter box trained

Approximately how many hours per day is animal home alone?

How is the animal contained in the home when left alone?

Loose

Crated

Other *Explain in additional comments

If outside, how was this animal confined?

Tied/Chained

Free Running

Kennel/fenced yard

When off leash/loose, will this animal run away?

Often

Sometimes

Never

Please explain more concerning off leash/loose question.

Would you consider this animal:

Free Text

Please comment on how the animal(s) relate/interact with the following:

*This helps find appropriate foster homes if available.

Men

Women

Children

Strangers

Other Dogs

Other Cats

Farm Animals

Deer/Wildlife

Please indicate which, if any, of the following behaviors have been a problem in the past/currently.

Comments concerning behavior issues. This helps foster home if one available.

Has this animal ever bitten anyone?

No

Yes *Explain below

Explanation for bite incident(s)

Why do you have to give this animal up at this time?

Additional comments/explanations for questions above and/or any additional information.

Free Text

You agree that you are irrevocably transferring and surrendering to Heart Animal Rescue legal ownership of the animal(s) on the date of surrender. This gives us complete authority to take whatever actions in our sole judgment are necessary and in the best interest of the animal(s). HEART will work to place your animal(s) into a good home. In an attempt to find a good lifetime home, Heart Animal Rescue works with other rescue groups and may in the best interest of the animal(s), please him/her with them. Your signature surrenders all claims and/or rights to the animal(s) listed on this form and by signing, you are giving Heart Animal Rescue authorization to make judgments regarding this/these animal(s) well-being and potential euthanize if the animal becomes terminally ill or deemed aggressive.

Your Signature/Name

Date

If you would like to make a donation to Heart Animal Rescue, please indicate as we appreciate donations to help the animals.

YES, I have read and understand the submission process & will contact Heart Animal Rescue if no email is received.

Yes

Surrender Form

Surrender Form

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