Pet Surrender Request

Pet Surrender Request
This application asks detailed information about your pet’s health, behavior, habits, likes, and dislikes. This is really helpful for the people considering your pet for adoption and helps us decide what kind of home would be best for them.

This information also helps determine if your pet is a good candidate for our adoption program. Please be honest when answering these questions; let us know if your pet has a history of biting, refuses to use the litter box, has a serious or chronic medical condition, or any other problem so that we can ensure we have the finances and ability to give your pet the care he/she needs.

Please note: H.A.L.O. manages animal intakes based on our space and resource availability. We generally remain at capacity and operate off a lengthy Surrender Request List to bring in new pets as space is made. Because of this, we must additionally require that all new pets coming to us are able to meet the following requirements:

- ALL pets (cats, dogs, & small pets) must have temperaments that would allow them to be handled safely and without incident by our Care Staff upon intake.

- Medium to Large sized dogs must be able to be introduced to another energy-neutral dog of similar size without displaying aggression at the time of intake.

- Due to the length of our current waitlist, we are unfortunately unable to add any more dogs with bite histories AND/OR major aggression issues to our waitlist at this time. If you are unsure whether your pet falls into this category, please email us at halonokillrescue@gmail.com!
Name of Owner(s)*

First NameLast Name
Animal's Name:*
Sex:*

MaleFemaleUnsure
Age of Pet:*
Species:*
Approximate Weight (in pounds):*

1-1010-2525-4040 - 6565+
Breed of Pet: *
Is this pet on monthly FLEA prevention?*

YesNoUnsure
Brand and date of last FLEA prevention given:
Is this pet on monthly HEARTWORM prevention?*

YesNoUnsure
Brand and date of last HEARTWORM prevention given:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Was pet adopted from H.A.L.O.?*

YesNoUnsure
If no, please list the name, address, and telephone number of the person/place you obtained the pet: *
Have you attempted to return the pet to where you obtained them from?*

YesNoNot Applicable
If yes, what was reason they were not able to take them back?
How long have you owned this pet? *
Tell us why you are unable to keep your pet (check all that apply):*

Home ForeclosureAllergicClaws/Destroys FurnitureWon't Use Litter BoxBitesHealth of PetDivorce/Relationship IssuesChases AnimalsCost/FinancialEscapesDestructiveSoils In HouseLitter Box OdorToo YoungKilled/Hurt An AnimalMovingPet Is Sick/InjuredNot Good w/ KidsHealth of OwnerNew BabyNo TimeOwner DiedNot FriendlyCannot Provide Care For PetLandlordPlay BitesDoesn't Get Along With Other PetsToo Playful / EnergeticPregnant OwnerPossessive/TerritorialSheds Too MuchOwner Is In Hospital / Nursing HomeCan't Find Housing That Allows Pets
*Please provide further details: *
Would you like resources to possibly work with the reasons for rehoming in order to possibly help keep you and your pet(s) together? Ex: Food/Supply Assistance, Training Referrals, etc.*

YesNo
When is the latest date the pet needs to enter the shelter by? *Please keep in mind that rescues often operate off a wait-list due to the high volume of surrender forms received. *
Medical Information
1. Name, phone number, and location of pet's most recent vet clinic?*
2. First and last name of owner on records:
3. Is this pet spayed/neutered?*

YesNoUnsure
4. Is this pet microchipped?*

YesNoUnsure
5. How does your pet react to being at the vet's office?*

Fine/NormalNeeds A MuzzleNeeds SedationReacts Poorly To Other PetsAggressiveUnknownShy/FearfulReacts Poorly To Restraint
6. How does your pet react to being bathed/groomed or having nails trimmed?*

Fine/NormalNeeds A MuzzleNeeds SedationWhines/CriesAggressiveUnknownReacts Poorly To RestraintNervous But Okay
7. Is your pet up to date on their yearly vaccinations? (Rabies, DAPPv, Bordetella, etc.)*

YesNoUnsure
Date of pet's most recent vaccines:
Date(s) of vaccination
8. Has your pet had a fecal exam for parasites done in the past year? If yes, when and what were the results?
9. Has your pet been tested for heartworm test (dogs) or FIV/FeLV test (cats) in the last year? If yes, when and what were the results?
10. If pet is a cat, is it declawed?*

Yes, Front & BackYes, Front OnlyNoUnknown
11. Does your pet have any health problems/concerns?*

YesNoUnsure
If yes, please describe health conditions and list all required medications:
12. Does pet have allergies that you are aware of? If so, please list allergy & symptoms that occur if exposed: *
13. Feeding Instructions - Brand of food? Canned, dry, or mixture? How much/how often is pet fed? Please include any special feeding instructions you wish to share with the new owner.*
Pet Personality Profile
1. Check all options that best describe your pet:*

ActiveAffectionateCouch PotatoAggressiveActive At NightNervousEscapesFearfulChews ObjectsLonerBehavedDominantDocileFriendlyPlay BitesGentleHigh EnergyHigh StrungHyperRelaxedVocal/Meows or Barks A LotRoughScratchesJumps On Counters

2. Please check the options that best describe how your pet reacts to people:*

	Men	Women	Strangers	Children
Likes
Tolerates
Avoids/Nervous
Hisses/Growls
Bites/Snaps
Unknown

3. Please check the options that best describe how your pet reacts to other animals:*

	Familiar Dog	Familiar Cat	Strange Dog	Strange Cat	Small Animals	Wildlife
Likes
Avoids
Hisses/Growls
Swats/Snaps
Bites/Attacks
Chases
Plays
Unknown

4. Check all that apply. Currently, your pet lives with:*

One DogOne CatOther Types of PetsMultiple DogsMultiple CatsNo Other PetsChildren 0-6yrs oldChildren 7-12yrs oldChildren 13yrs+
5. Please check all that apply. My pet gets along well with:*

DogsCatsSmall Pets (Rabbits, Guinea Pigs, etc.)None of the aboveUnknown
6. Is your pet housebroken?*

YesNoPartlyUnknownUses Potty Pads
If partly, describe how often and where accidents occur:
7. Has your pet bitten anyone before? If yes, who did the pet bite and how long ago did the incident(s) take place? *
Please describe the severity of the bite(s):*

NipBroke SkinNeeded Medical AttentionSurfaceDeepPet has not bitten
In your opinion, what triggered the bite(s)?
8. Does your pet have any behavioral problems (needs training, barks excessively, leash reactive, etc.)? If yes, please describe:*
9. Where is your pet kept while you are home?*

BathroomFree Run of HouseSeparate RoomScreened PatioGarageOutsideKennelLaundry RoomOther/Unknown
10. Where is your pet kept when he/she is home alone?*

BathroomFree Run of HouseSeparate RoomScreened PatioGarageOutsideKennelLaundry RoomOther/Unknown
11. Where does the pet sleep at night?*

Free Run of HouseIn Other RoomOutsidePet Bed In My RoomMy BedKennelOther/Unknown
12. If/when pet goes outside, it is:*

SupervisedConfined Screen PorchWalked On LeashUnsupervisedFenced In YardPet Does Not Go OutsidePlay PenTie Out / TetheredOther/Unknown
13. How many hours a day is your pet typically left alone?*

Never1-23-56-78 or moreOvernightUnknown
14. Please describe how pet reacts to being left alone. Are they noisy, destructive, calm, nervous, etc.? *
15. How does your pet react to riding in the car?*

Likes ItFineGets Sick/EliminatesNervousNeeds To Be In CarrierNeeds To Be TetheredUnknown
16. Has your pet ever escaped before?*

NeverOccasionallyFrequentlyAlwaysUnknown
17. Please describe pet's usual method(s) of escape:*

Pet Does Not EscapeDarts Out DoorJumps/Climbs FenceOpens DoorsBolts On LeashPaws Out ScreenDigs Out of YardUnknown
18. Is pet allowed on furniture?*

With PermissionYes, FreelyNoUnknown
19. Does pet enjoy swimming/playing in water?*

YesNoUnknown
20. Is pet crate trained?*

YesNoPartlyUnknown
21. Describe any training? Tricks?*
22. Things your pet likes or enjoys? *
23. Things your pet dislikes or is afraid of?*
24. Anything special, unusual, or endearing you could share about your pet?*
25. Are you willing or able to help cover the cost of caring for your pet until he/she is adopted?*

YesNo
If yes, how much would you like your donation to be for?
Upload an image of your pet! If photo size is too large, please e-mail your photo to halonokillrescue@gmail.com after submitting this form with the subject line "Surrender Photo". Your form is not considered complete and may not be processed until photo is received.

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If you pet is current on vaccines, please upload their medical records here. If the size is too large, please e-mail your records to halonokillrescue@gmail.com after submitting this form with the subject line "Surrender Medical Records".

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In signing and submitting this document, I,FIRST & LAST NAME, do certify that I am of legal age to give consent and do hereby voluntarily and irrevocably give, donate, surrender and release to Helping Animals Live And Overcome (H.A.L.O.) the animal(s) in question on this form.

I have disclosed any and all material information regarding the medical and behavioral history of said animal(s). I willfully surrender all medical records and information and give H.A.L.O. and it's representatives permission to contact the treating veterinarian for any records or information which might be in their possession.

I acknowledge that, once relinquished, H.A.L.O. has made no promises regarding the surrendered animal(s) beyond the inclusion in its care and adoption program.

I hereby certify that I am the rightful owner/keeper/caretaker= of the animal(s) who is/are the subject of this Pet Surrender Application. I release and discharge H.A.L.O. from any and all claims, obligations, liabilities and causes of action whatsoever arising out of or relating to the claims, obligations, liabilities and causes of action which may be asserted by other parties.

I understand that by surrendering my property rights to the animal, the animal will not be available to be returned once relinquished. I further certify that I have read and understand the terms of this Animal Surrender Application.
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Pet Surrender Request

Medical Information

Pet Personality Profile