DOG SURRENDER FORM

Name:*

Email:*

Phone Number:*

Address:

Name:

Age/D.O.B if known:

Breed:

Sex:

MaleFemale

Registration Number if Registered:

Microchip Number if Microchipped:

Spayed/Neutered:

YesNoDon't Know

Vaccinated:

YesNoDon't Know

If Vaccinated, Which one/s?

Parvo VirusLeptoKennel Cough

Date of last vaccinations:

Date

Date of Last Flea Treatment:

MonthDayYear

Date of Last Worm Treatment:

MonthDayYear

Please describe in full the reason why you would like to surrender/rehome your dog:

Is there a date the dog needs to be rehomed by?

How long have you had your dog?

Where did you get your dog?

What height fences would your dog need/what height do you have?

Has your dog lived/been around children?

YesNo

If yes, how old and how did your dog react?

Has your dog lived with/been around other dogs, cats, stock or any other animal?

DogsCatsStockOther

If yes, how did your dog react?

Has your dog ever had a incidents we should be aware of? Was animal control involved?

YesNoYes, Animal Control was involved.

If yes, please explain what happened in the incident:

Is there any medical conditions that the dog has that we should know about?

YesNo

If yes, please explain them:

Does or did your dog have any behavioural issues we should know about?

YesNo

If yes, please explain:

I Am The Legal Owner Of: (Dog's Name)

I understand that completing this form does not guarantee a place for my dog within the rescue. This decision will be made after receipt of this form.

YesNo

If Harmony & Hope agrees to take this dog into care, I agree to giving up all rights of this dog. The dog will not come back into my care once it has been given over if this is a surrender. - I give permission for this dog to be advertised on social media platforms and Trademe. - I acknowledge that the rescue will take an adoption fee from the new owners to go towards costs for this dog and the next one that comes into our care. - I declare that the information I have provided on this form to be accurate and truthful (if not I am liable for costs involved with anything that may happen in regards to this dog).

Please Read and Agree:

Yes I AgreeNo I Do Not Agree

Full Legal Name:

Signature

Todays Date:

MonthDayYear

DOG'S DETAILS

AGREEMENT