Animal Surrender (Intake) Agreement

Form Date *

Date

Please choose 1 *

Animal Surrender Animal Intake

Intake from: *

Highlands LCDAC Birth Stray/Rescue Other

Current Owner Name *

First Name Last Name

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Driver's License/ Identification Number *

I hereby surrender the animal listed below to Fur and Tails Animal Rescue:

Type of Animal *

Canine Feline Other

Animal Name: *

Animal Age: *

Animal Breed: *

Animal Color: *

Please upload an image of the animal:

Animal Sex *

Male Female Neutered Male Spayed Femal Unknown Other

Please tell us about the animal's temperament: *

What is the animal afraid of?, What's it's favorite thing to do?,

Reason for surrender: *

How did you acquire the animal? *

Include

Is the animal Microchipped? *

Yes No Unknown N/A

Microchip Number

Microchip Registration Company

Is the animal up to date on required vaccinations? *

YES NO N/A Unknown

Name of Veterinarian

Phone Number

Please enter a valid phone number.

Medical or Health conditions: *

List any current medications: *

Include parasite (flea /heart worm preventive)

I certify that I am the rightful owner of the animal(s) to be surrendered. *

YES NO

I certify that the animal(s) have not bitten anyone in the last 14 days. *

YES NO

You agree that Fur and Tails Animal Rescue makes no promises regarding the future placement of your pet. *

YES NO

I agree that a monetary donation and/or volunteer hours is required for surrender of a pet.

YES NO

I agree that surrendering a pet is a final action. When this form is submitted you will have no rights to the animal. If you change your mind, you will be required to follow the same process as any prospective adopter, which includes an application, donation and/or a home review. Additionally, you will not have any advantage over other applicants. We make adoption approvals based on the best fit for the animals needs. *

YES NO, stop this process. I am keeping my animal.

By Signing below;

I agree to surrender all ownership and rights to the above said animals to Fur and Tails Animal Rescue.

I agrree that this is a final action and cannot be recinded. If I decide to apply to adopt this animal again, I will be required to follow all new adoptor requirements, and I may not be chosen as the adoptor. A 14 day hold, based on the animal's status, may be required.

Fur and Tails Animal Rescue makes no claims regarding the future status of the animal.

I give permission to Fur and Tails Animal Rescue for access to all medical records o for this pets.

I certify that all information on this form is true and correct, and answered to the best of my ability.

I agree to release and discharge covenants to hold harmless Fur and Tails Animal Rescue.

The undersigned hereby releases, discharges, covenants to hold harmless and indemnify for all costs Fur and Tails Animal Rescue, it's Board of Directors, Officers, Volunteers or any official agent from any and all claims for damages, expenses, or actions arising out of any act or occurrence pursuant to this contract and/or conduct of said Fur and Tails Animal Rescue.

I agree this is a legally binding document.

Signature

Clear

Animal Surrender- Intake Form