Owner Surrender Form

Owner Surrender Form
Date*

MonthDayYear
Date
Name of dog*
Age*
Breed*
Weight*
Sex*
Dog color(s)*
How long have you been the owner?*
Where did you get the dog from?*
Reason for surrender*
Amount of time we have to find placement*
Name of veterinarian/animal hospital*
Veterinarian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Veterinarian Phone Number*

Area CodePhone Number
Date of last veterinarian visit*

MonthDayYear
Date
Scars, injuries, or tattoos?*
On Heartworm Preventative?*

YesNoOther
If yes, name of Heartworm Prevention
Date last administered:

MonthDayYear
Date
Current on Rabies vaccine?*

YesNo
Date of last Rabies vaccine:*

MonthDayYear
Date
Current on DHLPP?*

YesNo
Date of last DHLPP:*

MonthDayYear
Date
Current on Bordetella Vaccine?*

YesNo
Date of last Bordetella vaccine:*

MonthDayYear
Date
Date dewormed:*

MonthDayYear
Date
Type and/or brand(s) of dog food in diet*
How often and when do you feed the dog?*
Frequency the dog needs to be walked*
Crate trained?*

YesNoOther
Housebroken?*

YesNoOther
ls the dog friendly with other dogs?*
ls the dog friendly with cats?*
ls the dog friendly with strangers?*
Dog's experience with children?*
Explain any training the dog has, if any, and techniques used*
Any behavioral issues, specific tears, traumatic experiences, etc.*
Release of Ownership

I agree and understand that I am giving up all rights of possession and ownership of this dog. I also understand and acknowledge that I will not be able to redeem said dog at any time. I agree and understand that said dog is now "sole property" of Shelter Free Rescue NY. I further agree to submit any and all medical information. l promise that all the information I provide is accurate and Shelter Free Rescue NY will not be held liable or chargeable for any false information or misrepresentations that l submit on this from. Furthermore, l truthfully and honestly complete and sign this Owner Surrender Form as said dog's sole or primary owner. l am not surrendering a dog that belongs to any other person, firm, or organization.
Print Name*
Signature*

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Date*

MonthDayYear
Date
Email Address*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Driver's License #*
Date of Birth*

MonthDayYear
Date
The undersigned acknowledges that they have:

1) Read this agreement in its entirety
2) Had the opportunity to see the advice of counsel
3) Fully understand the agreement
4) Execute this agreement voluntarily and of their own free will
5) Are completely authorized to enter into the terms of and conditions of, and be bound by, this agreement.
Signature

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In consideration of receiving any [organization name] foster animal, I, as a foster caregiver, herby release [organization name], its officers, agents and employees from all claims of injury or damage that a fostered dog/cat/other may cause me or my property. I agree to hold harmless, defend and indemnify [organization name], it's officers, agents and employees from any and all claims of liability to other people for injuries.
Should be Empty:

Release of Ownership