Animal Surrender

Animal Surrender Agreement

Surrendering your pet can be a difficult and painful experience. We at Hart 2 Heart Animal Rescue want to help you through this situation so that you are comfortable knowing that your surrendered animal will be well taken care of and loved. The information you provide about how your pet behaved in different circumstances while he or she was living with you will help us find the most suitable home for your animal and to effectively counsel the new family. Your open and honest answers are very necessary and appreciated so that we can do careful and successful adoptions.

By signing below, I certify that the information I am about to provide is accurate and truthful to the best of my knowledge.

Contact Information

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
-

Email*

Cell Phone*

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How did you hear about Hart 2 Heart Animal Rescue?*

What is the animal's name?*

Gender:*

What is the age of the animal?*

Breed:*

Coat color/markings:*

Hair Length*

Spayed or neutered?*

Yes

For cats, Is the cat declawed?*

Yes

How long have you had this pet?*

What is your relationship to the pet?*

From where did you get this pet?*

If from another shelter or rescue, please provide name:

Why are you giving up this pet?*

If we could help you resolve this issue, would you be interested in keeping the animal?*

Yes

Have you attempted to find a new home for this animal?*

Yes

How many homes has this animal had, including yours?*

What is your age range*

What other animals live with this pet?

Dogs	Cats
Other

What is your pet's favorite brand of food?*

What type of food do you feed your pet?

Dry only	Canned only
Dry and canned	People food

What types of treats does your pet enjoy?*

How often do you feed your pet?*

Does your pet vomit after eating?*

Yes	No
Sometimes

Does your pet have any allergies, problems or injuries?*

Yes

How would you describe your pet's behavior most of the time? (Please check all that apply)

Active	Friendly
Couch Potato	Shy
Playful	Quiet
Talkative	Affectionate
Lap cat	Fearful
Independent	Aloof
Fearless	Solitary
Aggressive

How does your pet usually react when you or another family member does any of the following: Pet/stroked:

Never tried	Enjoys
Allows	Afraid
Hisses or swats	Runs away
Bites or claws	None of these

Pick up / Hold

Never tried	Enjoys
Allows	Afraid
Hisses or swats	Runs away
Bites or claws	None of these

Trim nails

Never tried	Enjoys
Allows	Afraid
Hisses or swats	Runs away
Bites or claws	None of these

Does your cat use the litter box?*

Yes

Has your pet ever eliminated inappropriately in the house?*

Yes	No
Sometimes

If yes, please explain

Have you sought medical advice/help from a veterinarian or other professional for inappropriate elimination?*

Yes

Please provide the name and contact information for your Vet:*

Please describe what measures you have taken to correct this problem:*

Where does your pet spend most of his/her time?

Inside the house, runs free	Inside the house, in cage
Outside the house, runs free in neighborhood	Inside and Outside
Other

How long is your pet left alone, without people, during the week?*

Never	1 -3 hours
4 - 8 hours	9 - 12 hours
over 12 hours

When your pet is left alone, is she/he: *

Outdoors	Free in home
Confined to a room	In a cage
Other

When you are home, where does your pet spend his/her time:

With me	In the same room
In another room	Hiding
Outside	Other

What toys does your pet like?

Balls	Wands
Plush	Squeaky
Interactive	Catnip
Bones	Other
None

Does your pet often engage in play with people?*

Yes	No
Sometimes

Is your pet scared of anything?*

Yes

If yes, please provide details:

How does your pet react to people she/he knows or family members?

Never encounters	Friendly
Fearful/Hides	Hisses/Swats
Bites	None of these

How does your pet react to men?

Never encounters	Friendly
Fearful/Hides	Hisses/Swats
Bites	None of these

How does your pet react to women?

Never encounters	Friendly
Fearful/Hides	Hisses/Swats
Bites	None of these

How does your pet react to children?

Never encounters	Friendly
Fearful/Hides	Hisses/Swats
Bites	None of these

How does your pet react to other animals?

Never encounters	Friendly
Fearful/Hides	Hisses/Swats
Bites	None of these

When was your pet's last veterinarian visit?*

Within last six months	Within the year
Over a year	Never been

When was your pet's last rabies shot?*

Within last six months	Within the year
Over a year	Never been

When was your pet's last distemper shot?*

Within last six months	Within the year
Over a year	Never been

Has your cat been FIV/FeLV tested? *

Yes

When was the test and what was the result?*

Do you give permission to H2H to verify with your veterinarian that pet vaccinations are current?*

Yes

Does your pet have any past or present medical conditions?*

Yes

If yes, please explain:*

Is your pet currently on any medications or special diet?*

Yes

If yes, please explain*

Is your pet microchipped?*

Yes

If yes, please provide microchip information*

Are you prepared/willing to proivde a minimum donation of $125 to surrender your pet to our care?*

Is there any addiitonal information you wish to tell us that would be helpful?*

I hereby certify that I am the lawful owner of the animal referenced above, and I have full power and authority to surrender the animal to Hart 2 Heart Animal Rescue. No other person has any legal or equitable ownership interest in the animal. I voluntarily relinquish all ownership of this animal to Hart 2 Heart Animal Rescue and understand that no guarantees are made as to the final disposition of the animal. I understand that Hart 2 Heart may rehome, transfer or euthanize the animal as deemed necessary by agents of the organization. I understand that Hart 2 Heart Animal Rescue is not obligated to reveal to me the final disposition of this animal and that she/he will not be used for experimentation. I further agree not to hold Hart 2 Heart Animal Rescue, its employees or members of the Board, liable for any damages or penalties resulting from this transfer. Hart 2 Heart Animal Rescue has my permission to contact my veterinarian for any necessary information pertaining to the animal, and I hereby consent to the release of any and all medical information by any medical provider. To the best of my knowledge, the aforementioned animal has not bitten a human being or another domesticated animal in the past ten days. I understand that this is a legally binding document for the surrender of my animal to Hart 2 Heart Animal Rescue. I have read and fully understand this Surrender Agreement. I accept and abide by its terms. By checking the box below, I affirm and agree to the above. *

I agree and attest to the above information and the validity of this Agreement.

*=required

Saving one animal won't save the world, but it will save that animal's world.

Animal Surrender Agreement