Surrender Form

H.E.A.R.T.

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Due to web provider issues which they are working on, please use this form below to submit applications.

SURRENDER FORM
Please fill out this form as thoroughly as possible. You can electronically submit below or print off and mail to HEART, Box 322, Decorah, IA 52101. A HEART representative will be in contact with you within 12-24 hours. If you have questions with this form or in general, you can email us at heartrescue2016@gmail.com.

* Indicates required field

Name *

First

Last

Street Address *

City *

State *

Zip Code *

Home Phone/Cell Phone *

Email *

Animal(s) Name *

Spayed/Neutered *

Yes No

Sex *

Male Female

Breed *

Age *

Age obtained & from where? *

Vet Clinic Name/Address/Phone *

Is animal current on vaccinations? *

Yes No

If "No" to current vaccinations, please explain or NA if Yes was marked *

Does this animal have any medical problems? *

Yes No

If "Yes" to above, please explain along with any medications they are on. *

YES, I give permission for a HEART Volunteer to call and verify my animal's vet records. INITIAL BELOW *

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 when left alone? *

Loose Crated Other *explain in comments at the end

How would you describe this animal? *

Inside Outside Both *explain in 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

Explain answer to off leash/loose question *

Would you consider this animal: *

Friendly Shy Aloof Submissive Dominant Stubborn

Please comment on how the animal(s) relates to the following:

Men *

Women *

Children *

Strangers *

Other Dogs *

Cats *

Farm Animals *

Deer/Wildlife *

Please indicate which, if any, of the folowing behaviors have been a problem in the past: *

Over-Activity Barking Digging Inapproriate chewing/scratching Counter jumping Separation anxiety Food aggression Possession aggression Climb/jump fences Dig in trash Chase cars Jump on people Urine marking Other/additional

Comments concerning behavior issues *

Has this animal ever bitten anyone? *

No Yes *Explain below

Explanation for any biting someone *

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

Please add any additional comments/explanations in this section. *

You agree that you are irrevocably transferring and surrendering to HEART 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 works with other rescue groups and may in the best interest of the animal(s) place 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 authorization to make judgments regarding this/these animal(s) well being and potential euthanize if animal becomes terminally ill or deemed aggressive.

Your signature/name *

Date *

If you would like to make a donation to HEART, please indicate as we appreciate donations to help with the animals. *

IMPORTANT NOTICE BELOW *

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

Submit

*IMPORTANT NOTICE: Due to occasional internet server and email issues beyond our control, submitted forms may NOT be received by HEART even though you get a successfully submitted confirmation response. If HEART receives your submission, we will ALWAYS send you an email to let you know we received it typically within no more than 12 hours. If you do NOT receive our email, please do one of the following let us know of your submissing: 1) Email us at heartrescue2016@gmail.com or 2) Send us a Facebook message on our FB Page. You are also welcome to do either of the above notifications after you submit right away.

Due to web provider issues which they are working on, please use this form below to submit applications.

© 2016 H.E.A.R.T. Helping every Animal Rescue Team