Dog Surrender Application

Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dog Name
Breed/Mix
Dog age
Gender

MaleFemale
Vaccination Status

VaccinatedNot vaccinated
Please upload vaccination card

Cancelof
If yes please provide the microchip number
Known health issues/Medical conditions
Reason for surrender
Any other information that may help us care for your dog
Suggested donation to help cover care costs: £100

I am able to make a donation of £100I can contribute a smaller amountI am unable to make a donation at this time
By submitting this form, I certify that I am the legal owner (or have legal authority to surrender) the animal described above to Congleton Dog Rescue.

I relinquish all rights of ownership and entitlement to information regarding the animal’s future.

I authorize the release of any veterinary records and confirm all information provided is accurate and complete to the best of my knowledge.
Type Name In Block Capitals Below
Date

YearMonthDay
Date
Should be Empty: