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Intake/Surrender Form and Agreement
We understand that surrendering a pet is never easy.Whether you’re making the difficult decision to part with a beloved companion, or you've gone out of your way to help a stray or abandoned animal, please know that your compassion has not gone unnoticed. At Keeks' Birdhouse, Inc., we approach every intake with empathy, respect, and a commitment to doing what’s best for the animal. Your honesty and care help us provide them with a safe, loving future.
Date
-
Month
-
Day
Year
Intake Type:
Owner Surrender
Stray
Transfer
Other
Surrendering Party Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Driver’s License or ID #:
Animal Information
Name of Animal (if known):
Species:
Bird
Reptile
Small Mammal
Other
Breed:
Age/DOB (if known):
Sex:
Male
Female
Spayed/Neutered?:
Yes
No
Unknown
Color/Markings:
Microchipped?:
Yes
No
Microchip Number:
Health and Behavior
Any known medical conditions or injuries?
Current medications (if any):
Behavioral concerns (biting, aggression, anxiety, etc.):
Good with (check all that apply):
Dogs
Cats
Children
Adults
Other
House-trained or litter-trained?:
Yes
No
Unknown
History
How long have you had the animal?:
Where did you originally acquire this animal?:
Breeder
Shelter/Rescue
Found Stray
Family/Friend
Other
Why are you surrendering this animal?:
Surrender Agreement
I certify that I am the legal owner of the above-named animal or have legal authority to surrender it. I understand that by surrendering this animal, I relinquish all ownership rights. I certify the information provided is truthful to the best of my knowledge. I understand that the rescue will make every effort to rehome the animal but makes no guarantees. By signing this form, I agree to the following statements(please read and initial each item):
I affirm that I am the legal owner of this animal or havefull legal authority to surrender them.
Initials
I understand that once surrendered, the animal becomes the property of the rescue and will not be returned.
Initials
I understand that the animal may be evaluated for health and temperament, and decisions about care, treatment, or euthanasia will be made by the rescue based on their policies.
Initials
I have disclosed all known medical and behavioral issues truthfully.
Initials
I understand that the rescue may or may not be able to provide updates on the animal after surrender.
Initials
I am surrendering the animal voluntarily and without coercion.
Initials
I understand that no compensation will be provided for the animal.
Initials
I release the rescue from any future liability or responsibility related to this animal.
Initials
Print Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
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Should be Empty: