Surrender Form

Surrender Form
By signing this form, you are voluntarily surrendering the dog detailed below to Midlands Cleft Rescue. By doing so, you agree to the following terms and conditions:

I confirm that I am the legal owner of the dog, or otherwise have full authority to surrender the dog to Midlands Cleft Rescue. Should this authority later be disputed by any third party, I accept full responsibility for entering into this agreement.

Upon signing this agreement, full ownership of the dog, including all legal rights and responsibilities, is permanently transferred to Midlands Cleft Rescue.

I understand that once the dog has been surrendered, I will no longer have any claim, rights or entitlement to the dog, including requesting the dog’s return.

I give permission for Midlands Cleft Rescue to contact the veterinary practice listed on this form in order to obtain the dog’s medical history where necessary.

I confirm that all information provided within this form is true and accurate to the best of my knowledge.

I confirm that I have read, understood, and agree to the above terms and conditions.

Declaration

Midlands Cleft Rescue specialises in neonatal and medically complex animals, many of which have been deemed “non-viable” or advised for euthanasia prior to coming into our care. By surrendering your animal to us, you acknowledge that we are offering them a chance based on our experience, knowledge and available resources not a guaranteed outcome. Whilst we have successfully saved and rehabilitated many puppies and kittens that were previously considered unlikely to survive, not every animal can be saved despite intensive care and around the clock intervention. By signing this form, you understand and accept that due to the nature and severity of many conditions presented to us, survival cannot be promised or guaranteed. Midlands Cleft Rescue and its volunteers will always act in the best interests of the animal and provide the highest standard of care possible but we are not miracle workers and cannot be held responsible for outcomes beyond our control.

Personal Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Puppy Details
Breed :
Date of Birth

MonthDayYear
Date
Medical Condition / Disability :
Vet Details (if applicable) :
Signature
Should be Empty: