Owner Surrender Agreement

Date*

Animal Name*

Species

Animal ID #

Age

Breed

Sex

Male
Female

Spayed/Neutered

Yes
No

Has your pet bit or scratched a person in the last ten (10) days?

Yes
No

Date

Name

First Last

In what city?

Surrender History

Why are you surrendering your pet? Please provide as much info as you can; it helps us better care for your pet.

If we could help you resolve issues with your pet, would you be interested in keeping the animal?

Yes
No

Would need:

How long have you owned the animal?

How many homes has the animal had?

Where did you get the animal?

Does your animal have:

Tattoo
Microchip
None
Not Sure

Medical Information

Has your animal been to a veterinarian?

Yes
No

Veterinarian

First Last

City & State

Is he current on vaccinations?

Yes
No
Not sure

Has your pet been hit by a car, injured, or required other surgery?

Yes
No
Not sure

If yes, please explain:

Has your pet been diagnosed with and/or treated for any of the following:

(Check all that apply)

General Personality

How would you describe your animal most of the time?

(Check all that apply)

Loves kids:

Under 5 yrs
5-12 yrs
12-18 yrs
No patience with kids
Not sure how he his with kids

Good with men?

Yes
No
Not sure

Good with women?

Yes
No
Not sure

Good with cats?

Yes
No
Not sure

Good with dogs?

Yes
No
Not sure

What is the animal's favorite toy?

What brand of food has he been eating?

Food type:

Canned
Dry

Where does he like to sleep?

What, if anything, is he afraid of?

What, if anything has your animal been aggressive towards?

Dogs

How is your dog with livestock?

Good
Has worked livestock
Chases
Has killed
Not sure

Has he had any obedience training?

Yes
No
Not sure

If he has been trained, what kind of training was it?

Punishment
Positive
Reinforcement
Food/treat rewards
Clicker
Leash correction
E-collar
Other

Is he crate trained?

Yes
No

What commands does the dog know?

Does he come when called?

Yes
No

Has he been used for hunting?

Yes
No

Does he jump fences?

Yes
No

If yes, how high?

Does he dig under fences?

Yes
No

Is he house trained?

Yes
No
Somewhat

If somewhat, does he...

lift his leg?
urinate when he's excited?
urinate in his crate?
have accidents if left too long?
cannot be trusted alone?
other

How does he let you know when he/she has to go to the bathroom?

Where is he kept during the day?

At night?

Yes
No

Has he ever bitten a person?

Yes
No

If yes, did it break the skin?

Yes
No

Was animal control involved?

Yes
No

If yes to any, please explain in detail:

Is there anything else a future owner should know about your pet?

Surrender Agreement: I certify that I am the owner of or have the authority to surrender the animal described to GDU. I hereby relinquish all rights of ownership and any right to information on the disposition of the animal described to GDU. I also authorize the release of any veterinary records regarding the animal. I certify that to the best of my knowledge I have disclosed all of the information about the animal concerning health, behavior, history and anything else that may affect the safe placement of the animal in a new home.

Signed (enter your full name)*

Date*

Name*

First Last

Phone*

Address*

Street Address City State Zip/ Postal Code

If you are able, please consider making a donation now to help us care for your pet during his or her stay with us. Your donation will go to cover food, shelter, medical and other expenses. Thank you for bringing your pet to a rescue – we know it was a tough decision for you.

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