Surrender Form Email Pet Owner & Household Info Owner's Name * Address * Mobile Phone * Home Phone Email Address * Referred By If this dog is a stray, how long has it been in your possesion? Current family includes (please give children’s ages) Do you have other animals? (type, sex, age) Your Household activity level: QuietModerately ActiveActiveVery Active Pet Info THE MORE WE KNOW ABOUT YOUR PET, THE BETTER JOB WE CAN DO OF FINDING THE BEST POSSIBLE HOME FOR IT. PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AND HONESTLY AS POSSIBLE. Pet's Formal Name * Pet's Nickname * Pet's Gender * Male Female Spayed/Neutered? * Yes No Describe the Pet’s general temperament * Breed * Color * Weight * Current Age * Age at Purchase/Adoption * Date Pet will be available Where was the Pet adopted or purchased? * Please include name, state and phone number. Pet's Breeder or Adoption Agency * Please include name, state and phone number. Have you tried to contact the Pet’s breeder or adoption agency? Reputable breeders/agencies always take responsibility for the dogs they produce and usually want their dogs back if you cannot keep it, no matter what the age of the dog is now. * Yes No If you did contact the Breeder/Agency, what did they say? If not, why not? * Pets Likes & Dislikes Baths Does Not LikeToleratesLikesLoves it! Brushing Does Not LikeToleratesLikesLoves it! Car Rides Does Not LikeToleratesLikesLoves it! Cats Does Not LikeToleratesLikesLoves it! Children Does Not LikeToleratesLikesLoves it! Nail Trim Does Not LikeToleratesLikesLoves it! Other Dogs Does Not LikeToleratesLikesLoves it! Strangers Does Not LikeToleratesLikesLoves it! Water Does Not LikeToleratesLikesLoves it! Please elaborate on Likes/Dislikes * Is your Pet: House Broken * YesNo Crate Trained * YesNo Obedience Trained * YesNo Food Aggressive * YesNo Does your Pet: Chew * YesNo Bark * YesNo Jump on People * YesNo Come when called * YesNo Leash Trained * YesNo Run away/escape * YesNo Snarl or Snap? (Please be honest) * YesNo Show fear? (thunder, strangers, etc...) * YesNo Bite or have history of Biting Someone? * YesNo Bite or have history of Biting other animals? * YesNo Can you leave him/her unattended in the house for long periods of time without him/her damaging anything? * YesNoDon't Know Where is the Pet currently left when unattended? * Where is the Pet during the day? * Where does the Pet sleep at night? * Any special training tricks? If obedience trained, when and where? * Does your Pet jump Fences? * No, not a jumper outer. Will jump over 3ft fence. Will jump over 4ft fence. Will jump over 6ft fence. How high is the fence where the dog is kept now? * Feeding Instructions: Pet’s food brand: * How many meals per day? * Amount at each feeding? * Any special feeding needs? Veterinarian & Vaccinations Do you have a local veterinarian? * Yes No If yes, please enter Vet's Name, Address & Phone Vaccination Dates DA2PP Rabies Bordatella Corona FVRCP (for cats) FeLV (cats) Last Heartworm Test Date * Is the Pet currently on Heartworm preventative? * YesNo Preventative Brand What day of the month do you give it? Additional Info Why are you unable to keep the Pet? * Any additional comments, notes or information? Agreement By entering my name in the field below, I certify that I am the owner of, or I have full legal authority to surrender the Pet as described above to Saving Grace and Her Furry Friends, Inc. I certify that I have disclosed all information about the Pet concerning health, behavior, history and anything else that may affect the safe placement of the Pet in a new home, and that all statements made above are true and correct. I certify that the Pet has never bitten or been aggressive towards a human. I hereby relinquish all rights of ownership and any right to information on the disposition of said Pet. I also authorize the release of any veterinary records regarding the Pet. Saving Grace and Her Furry Friends, Inc. shall have sole and exclusive legal right to make all outcome decisions and take all actions deemed appropriate for the Pet. At no time shall Saving Grace and Her Furry Friends, Inc. be obligated to communicate the outcome of the Pet to you or any other party. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, suits, or otherwise against Saving Grace and Her Furry Friends, Inc. with respect to the Pet. Email or other electronically delivered signatures of the applicant shall be deemed to constitute original signatures and shall be binding. This contains the complete terms of the parties’ understanding and agreement and no other promises or terms, verbal or otherwise, may be relied upon. This agreement shall be construed under Florida law and venue shall be Broward County, Florida. * I have read and agree to the above statement. Name * This field constitutes a binding signature. Date Signed *