H.E.A.R.T.
Home
About Us
HEART Bylaws
Adopt
Adoption Application
Adoption Contract
Foster
Foster home application
Donations
SUPPLIES DONATION
Amazon donations
Links for Supporters
Surrender
Surrender Form
Courtesy Listing
Happy FUR-EVER Tails!
Jan-April 2018
May-July 2018
Contact
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 48 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
*
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 anmal 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.
*
HEART Volunteer
*
Date
*
Submit
Home
About Us
HEART Bylaws
Adopt
Adoption Application
Adoption Contract
Foster
Foster home application
Donations
SUPPLIES DONATION
Amazon donations
Links for Supporters
Surrender
Surrender Form
Courtesy Listing
Happy FUR-EVER Tails!
Jan-April 2018
May-July 2018
Contact