HEART Surrender Form
Please complete this form and submit. A HEART volunteer will confirm receipt of this submission with 12 hours by email, so if you do not receive confirmation, please contact us by email at heartrescueteam2016@gmail.com or send us a Facebook message on our page. Please also feel free to email us if you have any questions prior to filling out this form.
Legal Name *
Your answer
Street Address *
Your answer
City, State, Zip Code *
Your answer
Home phone/Cell phone *
Your answer
Email *
Your answer
Animal(s) Name *
Your answer
Breed *
Your answer
Age *
Your answer
Sex *
Spayed/Neutered *
Age obtained & from where? *
Your answer
Vet Clinic name/address/phone number *
Your answer
Is animal current on vaccinations? *
If "No" to current vaccinations, please explain.
Your answer
Does this animal have any medical problems?
If 'Yes' to above medical problems, please explain along with any medications they are on.
Your answer
Please initial & that gives HEART permission to call & verify animal's vet records. You may need to contact your vet clinic to release information as some clinics require this. *
Your answer
Housebroken? *
Approximately how many hours per day is animal home alone? *
Your answer
How is the animal contained in the home when left alone? *
If outside, how was this animal confined? *
When off leash/loose, will this animal run away? *
Please explain more concerning off leash/loose question. *
Your answer
Would you consider this animal: *
Please comment on how the animal(s) related to the following:
*This helps find appropriate foster homes if available.
Men *
Your answer
Women *
Your answer
Other Dogs *
Your answer
Children *
Your answer
Strangers *
Your answer
Cats *
Your answer
Farm Animals *
Your answer
Deer/Wildlife *
Your answer
Please indicate which, if any, of the following behaviors have been a problem in the past/currently. *
Required
Comments concerning behavior issues. This helps foster home if one available.
Your answer
Has this animal ever bitten anyone? *
Explanation for bite incident(s)
Your answer
Why do you have to give this animal up at this time?
Your answer
Additional comments/explanations for questions above and/or any additional information.
Your answer
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), please 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 *
Your answer
Date *
MM
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DD
/
YYYY
If you would like to make a donation to HEART, please indicate as we appreciate donations to help the animals.
Your answer
YES, I have read and understand the submission process & will contact HEART if no email is received.
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