Animal Surrender/Intake Request

Harlee's Angels Rescue, Inc.
Dog Surrender/Intake Request
If you need to rehome your dog, we accept dogs that are usually 40 lbs or less and good with dogs/cats/people. If your dog fits that criteria, please fill in and submit this form and follow the instructions at the bottom for sending us photographs.

The information you provide on this form will help us match your dog with an appropriate new home. Please be honest in your answers. HAR accepts dogs based on space available and temperament assessment not the medical condition of your dog.

We help all dogs regardless of the medical issue or condition. Make sure your honest with us so we know how to help your dog!
How many dogs are you surrendering?*

Single (1)Multiple (complete a form for EACH)
Your Name*
Your Email*
Your Phone*
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Animal's Name*
Breed*
Purebred? If no, please list the other breed
Color(s)*
Is the dog microchipped?
If yes, please provide microchip number and provider if you know the information.
Age or Date of Birth (list date of birth in other option field if you know it)*

Under 8 weeks8 weeks to 4 months4 months to 1 year1-3 years3-6 years6-9 years9+ yearsOther
Approximate Weight*

15 lb or less16-30 lb30-45 lbOver 45 lb
Are you the legal owner of the dog?*

YesNoOther
Are you this dog’s first owner?*
If no, please explain how many previous owners the dog has has and why it was rehomed.
How long have you had this dog?*
Where did you get this dog? (Breeder name, Pet store name, Rescue name, etc)
Medical Questions

HAR does not refuse a dog due to medical/health issues.The information below will help us prepare the materials and supplies needed to properly care for the dog. *Please note HAR and/or HAR Veterinarian will contact your Veterinarian if needed to verify any medical issues or obtain any medical records concerning the dog for HAR and HAR Veterinarian to properly treat and care for the dog. PLEASE SEND A COPY OF YOUR DOGS VET OR BREEDER RECORDS/PAPERWORK.
Current veterinarian name and phone number. .*
Has your dog had any Basic Vetting?*

Rabies VaccineDistemper/Parvo VaccineBordetella VaccineSpay/NeuteredHas had NO vettingOther
Has your dog had a recent heartworm test? Is it heartworm negative or postive? Has it been on heartworm preventative? If so, please list the date of last test, test results, brand and when last given. *
Has your dog been on any Flea preventative? Brand and when last given.*
Please select health issues (check all that apply)*

EyeEarBreathingHeartworm PositiveLyme PostitiveDiabeticLiver ShuntSeizures/epilepsyPancreatitisHeart ProblemsCancerTumorsBlindDeafAllerigesSkin issuesStomach issuesNothing, perfectly heathly
Does your dog have current injury that needs medical attention?*
Does your dog have an old injury?*
Tell us about the dog
Tell us about your dog*

Fine with other dogsFine with catsFine with young childrenBetter with older childrenNo kids for this dog, please!Crate trainedHousebrokenWorking on housebreaking needs some helpFriendlyEasy GoingChews, Digs, Climbs/Jumps FenceHigh energyNeeds structure & routineWalks well on the leash
Socialization*

Sweet and socialA little shy but warms up when you're niceVery shyDefinitely abusedFear biter
Where does your dog normally stay at night? (Be specific)*
Where does your dogn ormally stay during the day?(Be specific)*
How long is the dog alone during the day?*
Had any obedience training? What commands does it know?
How did you discipline your dog for bad behavior?*
Tell us more about your dog’s personality. Likes, dislikes, favorite toy, treat, rewards, ect. *
What kind of food do you feed your dog? *
Canned, Dry, Raw, Homemade, combination of dry/wet
Reason for Surrendering
Reasons for surrendering (check all that apply)*

New babyAllergiesNot enough timeMoving, cannot take the dogFound as a strayBehavioral problemsHealth Issues (Owner)Health Issues (Dog)Cannot afford careNew home
In order for HAR to properly place your dog in one of our foster homes we need you to answer the following question on the dogs behavior. Please be honest. Please select any Behavior Issues (check all that apply):*

Has shown aggression towards dogsHas shown aggression towards cats/small animalsHas shown aggression towards childrenHas shown aggression towards adultsHow are they with men/women as some can be afraid of certain genders and ethnic backgroundLoves to barkDestructive / separation anxietyPossessive of food, toys or peopleHyperactive / very high energyTrouble house training/markerDoes the dog chase? (cars, bikes, skateboards, animals, kids, people)N/A
Possessive of food, toys or people? Explain*
Has your dog ever been in a dog fight that caused injuries serious enough to send either dog to the vet?*
Has the dog ever bitten? If yes, who? (owner, friend, stranger, child, baby) Provoked? (defending itself or property, hurt, scared,tail or other part of body pulled)*
Please explain in detail why you wish to surrender your dog to HAR?*
Please take 3 good quality, well-lit photographs of the animal and email them to us at southernpugandbostonrescue@gmail.com with your name and the animal's name in the subject of the email. If you have any videos of the dog, please send us the links to them on youtube.
You agree that you have disclosed any and all material information regarding the medical and behavioral history of animal described above (termed "the animal") on this Harlee's Angels Rescue (termed "HAR") Animal Surrender Form. You willingly surrender all medical records and information and give HAR and its representative’s permission to contact the dog's veterinarian for any records or information which might be in the vet's possession or to the vet's knowledge. You acknowledge that HAR has made no promises regarding the surrendered animal beyond the inclusion in its care and foster program. You hereby certify that you are the rightful owner/keeper/caretaker/custodian of the animal who is the subject of this Animal Surrender Form and hereby surrender any and all property rights to the animal. You release, discharge and hold harmless HAR from any and all claims, obligations, liabilities, and causes of action whatsoever arising out of or relating to the ownership, possession, or disposition of the animal. You further agree to hold harmless HAR from and against any and all such rights claims, obligations, liabilities and causes of action which may be asserted by other parties. You certify that you are not aware of any other person who has or may claim a right of property to the animal. You certify that the animal has not bitten or scratched a human or another animal within the past 10 days if you have not disclosed the information above in the form. You understand that once you relinquish the animal, the animal will not be available to be returned. You further certify that you have read and understand the terms of this Harlee's Angels Rescue Animal Surrender Form. THIS IS A LEGALLY BINDING CONTRACT AND DOCUMENT FOR THE IRREVOCABLE SURRENDER OF YOUR ANIMAL(S) TO THE Harlee's Angels Rescue Inc.
With my signature I hereby certifythat I am the legal owner of this pet and I release all interests in the animal listed above to Harlee’s Angels Rescue.

Clear
Date*
When we take a dog in, we keep it in our home with our family and pets. Whether it takes weeks or months to find it a home, we keep the dog with us and incur the cost of its care and vetting. While a donation is not mandatory, we very much appreciate any contribution you can make. HAR rescue dogs regardless of age or physical condition and depend on the support of dog lovers to continue our work.
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Harlee's Angels Rescue, Inc.

Dog Surrender/Intake Request

Medical Questions

Tell us about the dog

Reason for Surrendering