First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Cell Phone*

Name of Animal Being Surrendered*

What is the sex of the animal?*
Choose one: Male Female

What type of animal do you wish to surrender?*
Choose one: Dog Cat Other

What is the breed of the animal being surrendered? (If unknown, please put best guess.)*

What is the age of the animal being surrendered? (If unknown, please enter best guess.)*

Do you have vet records to provide to us if we are able to admit your animal? Please provide name and city of the animal's most recent veterinarian.*

Is the animal up to date on all vaccines? (Up to date means they are currently up to date per vaccination requirements. If the animal only had them as a baby and they are now an adult, they are not up to date.)*

Has the animal been spayed or neutered?*
Choose one: Yes No

If animal is a dog, has he/she been tested for heartworm in the past year and are they currently on heartworm preventative?

Is the animal current on flea and tick preventative?*
Choose one: Yes No

Is your animal housebroken? If no, please give an estimate on the frequency of accidents and any other details you can provide.*

Is your animal crate/kennel trained? *

Where is your animal when left alone? (Kennel, free roam, blocked off in room, etc.) On average, how many hours a day is your animal used to being left alone?*

Does the animal get along with dogs? If no, please provide details.*

Does the animal get along with cats? If no, please provide details.*

Does the animal do well with children? If no, please provide specific details as to what ages the animal can safely be around.*

Does the animal have any aggression or fear towards adults of a certain gender? If yes, please provide details.*

Please provide all details about the reason for surrender. The more details you provide, the better chance we have of placing the animal. PLEASE be completely transparent and honest about the reasons for surrender.*

If the animal has had any medical conditions or accidents in the past for which they have been treated or will need to be treated, please detail them here.

I understand this is an application for surrender and does not obligate Hero's Haven Animal Rescue (hereinafter referred to as Hero's Haven) to admit my animal to their care. If Hero's Haven is able to find placement for my animal, my signature on this form will serve as a legal and binding surrender of the animal as property. If Hero's Haven is able to admit my animal to their care, I understand that by signing this form, Hero's Haven assumes full ownership of my animal and they may transfer ownership to another individual or rescue/shelter. I certify that my animal is in good health at the time of this surrender, unless otherwise fully disclosed on this form. I understand that if the health of my animal is compromised and unable to be restored to an acceptable quality of life, at any point, or the animal is deemed to be extremely aggressive and unable to be rehabilitated that Hero's Haven may opt to euthanize the animal. By electronically signing this form, I certify the animal belongs only to me and there is no other owner who has rights to or interests in this animal. I also understand this is a binding contract and if any false information about my animal is discovered after the surrender (temperament, health, etc.), the animal will be returned to me and I will be responsible for any costs associated with the false information incurred by Hero's Haven during the time they had my animal. Please type legal name and date in the box provided to electronically sign.*