Animal Surrender Agreement

The information you provide on this form will help us match the surrendered animal with an appropriate new home so please be specific and honest. There are many reason why an individual or family may need to surrender a pet, we are not here to judge, we are here to help. All information is kept strictly confidential and will only be shared when necessary as proof of ownership in order to provide necessary care for the animal. Should you feel uncomfortable giving certain information we may still accept the animal provided it meets certain criteria.

Should you wish to surrender more than one animal please complete a separate form for each.

If you experience problems with this form or the form submission please contact us at 978-345-2686 and we will assist you..

Surrendering Owner

Street Address
City      State      Zip Code

Day Phone      Evening Phone
Cell Phone

Email

Best time to call?

Information about the animal to be surrendered: Name      Male Female
Breed      Color & Markings
Age      Date Of Birth (if known)     Weight (lbs.)      Spayed/Neutered? Yes No

Your Veterinarian
Street Address
City      State      Zip Code
Phone

Date of s last vaccinations:
Rabies      Parvo/Distemper      Other
Explain

Date of last visit to the above Veterinarian
For?

Does this animal have a Microchip? Yes No
If yes, please enter the Chip Company and chip number

Has this animal been tested for Heartworm? Yes No
If yes, what was the result?

Does this animal have any injuries or health issues, past or present that we should know about? Yes No
If yes, please explain

Does the animal take maintenance medication or Daily Supplements (i.e Heartworm preventive)? Yes No
List
Reason

Do you have, rabies tag, microchip tag , written Vet statements that you are willing to surrender with this animal? Yes No
List which items you will surrender with the animal.

Do you agree that this surrender form, and your signature upon it, shall also serve as a Release for Vet Records? Yes No

Are you the only owner the animal has had? Yes No     How old was the animal when you got him/her
Where did you get this animal

Is this animal good with (check all that apply)
Children Male Animals Female Animals Cats Livestock

Is this animal inappropriate with (check all that apply)
Children Male Animals Female Animals Cats Livestock

Explain the inappropriate behavior in detail. (chasing cats, fighting, jumping children etc.)

Has this animal ever displayed aggressive behavior toward you or anyone else? (growling, chasing) Yes No
Please explain

Has this animal ever bitten you? Bitten anyone else? Yes No
If yes, who did the animal bite? (child, neighbor)?
Please explain what caused the biting behavior.

Is this animal possessive of food, bed, food bowl, a particular area in the home, or toys? Yes No
How does this animal react during these times?

Has this animal ever attacked another animal? Yes No
Please explain

Has this animal ever been attacked by another animal? Yes No
Please explain

Have you ever received written violations from a animal officer because of this animal? Yes No
If yes, explain

Where does this animal stay at night? Be specific.
Where does this animal stay during the day?
How many hours is this animal alone during the day?

Is this animal house trained? Yes No
Is this animal crate trained? Yes No
Is this animal leash trained? Yes No
Is this animal car ride trained? Yes No

Has this animal had any obedience training? Yes No
If yes from where and who was the trainer?

Does this animal know any commands?

Does this animal jump/climb/dig under fences? Yes No

Is this animal a problem barker? Yes No

Why are you surrendering this animal? Please be specific.

SURRENDER DONATION: Help A Hound, Inc. requires a surrender donation of the following:
A: $50.00 per animal that is up to date on vaccinations and sterilized.
B: $75.00 for an animal not up to date on vaccinations but is sterilized
C: $125.00 for an animal not up to date on vaccinations nor sterilized.
This money is used to help offset the cost of properly sterilizing the animal, normal and necessary Vet care, shelter, and food for this animal until a new and appropriate forever home can be found.

If this requirement is a hardship send us an e-mail after submission of this form explaining why it is a hardship. We will evaluate your request and make a decision as to whether we can reduce or waive the surrender fee. We are funded strictly by public donations and personal monies so these surrender donations are very important to us in caring for the pet you are surrendering to us. If we don't take a donation another pet goes without.

Help A Hound, Inc. at its' sole discretion will utilize all of its resources to ensure this animal is placed in a home that will be a successful match for both the animal and the family adopting the animal. Prior to this placement Help A Hound, Inc. will be responsible for food, shelter, care, and medical treatment for this animal.

By signing below you agree that you, your family members, your spouse, and /or any co-owner of the animal described on this form are irrevocably transferring and relinquishing to Help A Hound, Inc. legal ownership of said animal on the signature date of surrender and/or date of our acceptance thereof. This Agreement constitutes a contract, governed by and carried out to the fullest extent of the Laws of Massachusetts, in the County of Worcester. This agreement shall bestow upon Help A Hound, Inc. unobstructed authority to possess, own, and properly care for this animal at our sole discretion and judgment as is necessary and in the best interest of the animal.

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