RDK9 Animal Surrender Request Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail*

example@example.com

Address where the animal is currently:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

OwnFoster under my own accord and have full rights to the animalFoster through a shelter and all parties involved must discuss transferFoster for another person and do not have ownership rightsFoster for another rescue and do not have ownership rights

If the animal(s) being surrendered is/are not owned by you, please list who owns the animal(s) currently:

First NameLast Name

If the animal(s) is/are currently under another rescue please list below rather then “First & Last Name”

If the animal(s) is/are currently under another person’s or rescue’s ownership please list the address for current owner or rescue:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number for current owner or rescue:

Area CodePhone Number

TELL US ABOUT THE ANIMAL(S) YOU WISH TO SURRENDER

DogCatHorseOther

What is/are the name(s) of the animal(s) being surrendered? If there is more then one animal being surrendered then please separate with commas and please list all.*

What is/are the breed(s) of the animal(s) being surrendered to the best of your knowledge? If the animal is a mix, please separate with a /. If there is more than one animal being surrendered then please separate by commas and please list all.*

YesNo

How did you obtain the animal(s) being surrendered and how long have you had them?*

MEDICAL

SpayedNeuteredGeldedUnknown

YesNo the animal is not microchipped

YesNo but will have them done prior to surrenderUnknown and will have them done prior to surrender

NoYes, the animal(s) is/are currently illYes, the animal(s) has/have been exposed to illness but are not currently sickUnknownMultiple are being surrendered and at least one of them is ill

If the answer is yes to the above question please type what the animal(s) being surrendered is/are sick from or have been exposed to and their symptoms. If the answer is No, please type N/A.*

Please list what veterinarian (row 1) & farrier (row 2 if applicable) the animal(s) being surrendered has/have been seen by in the past. If unknown please type N/A across the first row. Please Note: the application will not be submitted if at least row 1 is not filled out:*

Rows	Full Name	Address	Contact Number
1
2

BEHAVIORAL

YesNo

If the answer is Yes to the question above please list and describe any issues the animal(s) being surrendered has/have. If the answer is No, please type N/A.*

YesNoUnknown

NoYes, aggressive towards other male animalsYes, aggressive towards other female animalsYes, aggressive towards male humansYes, aggressive towards female humansYes, aggressive towards children

Tell Us More: How old is/are the animal(s) you wish to surrender? Is/Are they good with other animals? Please state what they are or not ok with (other animal breeds/species) so we can make sure they are accommodated properly! Why do you wish to surrender the animal(s)? No judgement, we just need a clear picture of the situation!*

NoYes, within the past 6 monthsYes, within the past 12 monthsYes, but incident occurred longer then 12 months ago

YesNo

YesI wish to speak to someone about properly quarantining the animal through the rescue

GENERAL

Is the animal coming with any personal items ie bed, toys, food, kennel, medication, collar, leash etc?*

Yes, I will cover the spay/neuter/geld ($350-$1000)Yes, I will cover 6 months of food for the surrendered animal ($240)Yes, I will cover initial vetting appointment for the animal ($200)Yes, I will cover 6 months of flea/tick/heart worm prevention ($150)I will make a general donationI cannot afford to help at this time but I will make a donation in the future

Yes, I will cover the entire costYes, I will cover half of the costYes, I will donate a portion of the cost with a minimum donation of $200I’m sorry I cannot at this time but will make a donation in the future

ImmediatelyWithin the next 30 daysWithin the next 60 daysI am willing to foster the animal for an extended period of time and just need rescue help

PLEASE READ THIS DOCUMENT CAREFULLY & UNDERSTAND THAT BY SIGNING IT YOU MAY BE GIVING UP RIGHTS THAT YOU MIGHT OTHERWISE HAVE.

I Hereby certify that I am the rightful owner/keeper/caretaker/custodian of the animal(s) who is/are the subject of this Animal Surrender Form, hereinafter referred to as "the animal." If I am not the rightful owner/keeper/caretaker/custodian then I will provide the information to Regional Deployed K9 Inc on how to contact the person or entity that is. I hereby surrender any animal and all property rights to the animal. I understand that by surrendering my property rights to the animal, the animal may be transferred into the custody of Regional Deployed K9 Inc or another rescue. I also hereby certify that the animal is not under any quarantine circumstances due to bite report or illness. I understand that once I relinquish the animal, the animal will not be available to be returned. I further certify that I have read and understand the terms of this Animal Surrender Form.

Please Note: All animals surrendered to Regional Deployed K9 Inc MUST be up to date on vaccines at time of surrender or transport. If a health certificate is required for transport, that will be your responsibility to financially cover in its entirety as well as assuring it is done prior to transport. Please submit vaccination records to mgintzighayes@regionaldeployedk9.org along with any other medical records & photos/video of the animal.

Please Note: Completion of this form does NOT guarantee Regional Deployed K9 Inc will intake the animal, but please know and understand that no animal will be reviewed or accepted without the necessary medical documentation and photographs submitted via email.

Please Note: If the animal is surrendered to and accepted by Regional Deployed K9 Inc and you need the animal removed IMMEDIATELY, boarding can be arranged while awaiting pick up or transport but you are responsible for its cost in its entirety.

Signature

Name

First NameLast Name

Regional Deployed K9 Inc’s Animal Surrender Form: