Owner Surrender

Guardian Name

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region

County*

Primary Phone*

Secondary Phone*

Email*

Animal Information

Animal Name*

Animal Type:*

Dog
Puppy

Is this animal a stray?*

Yes
No

Animal Breed - Please be as specific as possible:*

Animal Age:*

Animal Weight:*

Animal Color:*

Is the animal spayed or neutered?*

Yes
No
Unsure

Where does this animal primarily spend it’s time?*

House - Indoors exclusively
Indoors / Outdoors
In a Garage / Porch / Outbuilding
Outdoors / Kennel / Tie out

List any medications your animal is currently taking.*

Please write “None” if your animal is not taking any medications.

Please describe any behavior issues (separation anxiety, housetraining issues, inappropriate marking, aggression, fear, etc.):*

Has your animal every snapped at or bitten a human? If yes, please explain.*

Has your animal ever snapped at or bitten another animal? If yes, please explain.*

Which of the following has your animal lived with in a home in the past:*

Children
Dogs
Cats
Reptiles
Small Animals

Is your animal able to safely live in a home with other dogs? If no, please describe.*

Please describe any medical issues (diabetes, injuries, illness, etc.):*

Please describe the reason for requesting re-homing services.*

How long have you been trying to re-home the animal?*

Is there a date by which the animal must be surrendered?*

Yes
No

Date the animal must be surrendered by:

Terms and Conditions

I understand that: 1. I am the legal owner of the above described pet and I have the authority to request surrender. 2. I understand that by surrendering my animal it becomes property of RCHS and may be immediately adopted, transferred to rescue, or euthanized if deemed not adoptable due to illness or behavior. 3. The completion of this form does NOT guarantee that my animal will be admitted into the adoption program at RCHS. 4. After I submit this form, an RCHS intake staff person will contact me within ten (10) business days to discuss the information I have provided and schedule an intake behavior evaluation. 5. All animals must complete a behavior evaluation prior to being considered for admission into the RCHS adoption program. 6. All animals accepted into the RCHS adoption program will be subject to a $50 surrender fee per animal. This fee must be paid upon surrender.

I have read and agree to the above terms and conditions.*

Guardian Name

Animal Information

Terms and Conditions

Contact Us

Sign up for our Newsletter