DOG OWNER SURRENDER APPLICATION

Name*

First NameLast Name

Street Address*

City*

Zip_code*

Phone*

Format: (000) 000-0000.

Email*

example@example.com

Dogs with vet records require a $50 donation upon intake. Animals that are not spayed or neutered require a $100 donation upon intake.

Reason for Surrender*

Dogs Name*

Breed*

Gender*

Age and Date of Birth*

YesNo

Color*

Distinguishing Marks

YesNo

If yes, describe the incident, and list the designation, date of designation, and county where made, if applicable.

Where does your dog spend most time? Indoors, outdoors or both?*

YesNoUses puppy pads in house

House training comments

Who is your Veterinarian?*

YesNo

Does your dog have allergies? If yes, please explain. *

Does your dog need medications? If yes, please explain. *

Does your dog have special needs? If yes, please explain.*

My dog has been crated.My dog has been muzzled.My dog needs to be muzzled before going to the vet or being groomed.

How long have you owned your dog?*

Where did you get your dog from?*

Tell us about how much training history your dog has.*

None, minimal, fully, extensive

Does your dog know any commands? If yes, please list here.

Completely reliableSomewhat reliableNot at all reliableUnknown

LowModerateHigh

Able to climb upAble to climb down4 or lessFull staircaseI can carry my dog up or down the stairs if neededMy dog needs help in and out of the carMy dog needs a ramp, step stool or to be picked up and placed in the car

My dog eats at specific times.My dog is allowed to eat all the time (free fed).

Brand of dog food my dog will eat.

Do you have any additional comments about the pet's interaction with people?

Do you have any additional comments about the pet's interaction with animals?

I certify that I am the owner or the authorized owner representative of the dog described above. Further, I certify that I have unrestricted and complete authority to surrender ownership of the dog to Parma Animal Shelter (PAS). I certify that the information above is accurate and to the best of my knowledge, the dog has not bitten any person or animal within the past 10 days.

While PAS euthanizes very few dogs, certain behavior or health related circumstances may make euthanasia necessary. I understand that PAS will determine the outcome of the dog in its sole discretion.

I hereby release PAS, its employees, volunteers, staff, agents and/or representatives from any and all claims of any nature, including but not limited to claims for bodily injury or property damage, which may be related to this dog. I further agree to defend, indemnify and hold harmless PAS from any and all claims, lawsuits, or judgments for damages of any nature, including but not limited to damages to property or for personal injury, brought by any person or entity, resulting from my ownership or possession of the surrendered dog, including attorney fees and court costs of any legal action.

This agreement shall serve as a certificate of transfer of ownership pursuant to ORC §955.11 and it may be so recorded. Therefore, I hereby voluntarily transfer full ownership of the dog, along with registrations or other ownership documents to PAS. This Agreement constitutes the entire understanding between the parties. This Agreement shall be construed according to Ohio law, and shall be enforced by the proper state court with jurisdiction over Parma, Ohio.

Signature of Owner*

Date*

Date

Signature of Health and Welfare Chair

Date

DOG OWNER SURRENDER

OWNER/GUARDIAN INFORMATION

ANIMAL BASIC INFORMATION

PROFILE INFORMATION