Surrender Form

Surrender Form

Doghouse Rescue Academy of Southwest Florida
By signing this form, I do hereby voluntarily and irrevocably give, donate, surrender and release to Dog House Rescue Academy, hereinafter referred to as DHRA, the following animal(s), hereinafter referred to collectively as “Animal(s)”
Dog Name
Please list Animal(s) that you would like to surrender: *
Is the dog good with *

Dogs Cats Small Animals Farm Animals NONE - MUST BE THE ONLY PET
Owner's Reason for Surrender *
List any medication(s) or allergies for the above mentioned pet(s):
Owner Information

Please provide the most up to date information
Owner Name *

First Name Last Name
Owner Mobile Phone Number *

Area Code Phone Number

Owner Address *

Owner Email *
Primary Email
Surrender Fee
Please note: Surrender Fees are considered a donation and are non-refundable. We will send you the invoice via PayPal.
Vet Information

I represent and warrant that I am the lawful owner of the Animal(s), and I have full power and authority to surrender the Animal(s) to DHRA. No other person has any legal or equitable ownership interest in the Animal(s).I have disclosed to DHRA all material information regarding the medical and behavioral history of the Animal(s). I willfully surrender all medical records and information pertaining to the Animal(s). DHRA has my permission to contact my veterinarian for any necessary information pertaining to my Animal(s), and I hereby consent to the release of any and all medical information by any medical provider.

Vet's Name & Address

Vet's Phone Number

Area Code Phone Number
Please attach all vet/medical records (i.e. Certificate of Vaccines)

Browse Files

Cancel of
I further acknowledge that I am releasing the Animal(s) completely voluntarily and that no representations, considerations, orpromises of any kind have been made to me by DHRA or any of its representatives.
List any particular concerns or things DHRA should know about the Animal(s) - good and not so good:
Owner Consent & Signature to Surrender

I understand that by releasing the Animal(s) to DHRA, I relinquish all ownership or other interest in the Animal(s). I will not seek further information about the Animal(s) and will not press DHRA for details. My contact with the Animal(s) terminates at the time of surrender. DHRA is under no obligation whatsoever to follow up with information about the Animal(s). I hereby release and forever discharge DHRA from any and all rights, claims, obligations, liabilities, and causes of action whatsoever arising out of or relating to the ownership, possession, or disposition of the Animal(s), and I agree to indemnify and hold harmless DHRA from and against any and all such rights, claims, obligations, liabilities, and causes of action which may be asserted by third parties. By signing below I state that I have fully read and understand this surrender agreement and I accept and agree to abide by its terms.
Owner Name - PRINT *

First Name Last Name
Owner Name - SIGNATURE *

Clear
Date of Surrender *
Should be Empty:

Owner Consent & Signature to Surrender