Animal Surrender Application

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By surrendering this animal you are relinquishing all rights and privileges to Rescue K-911. Transfer of ownership of this animal takes place once the animal is in our possession or dropped at the vet clinic of our choosing. Please provide as much information on the animal’s history to help us determine the best placement for this pet.

By submitting this application, you understand that Rescue K-911 has the right to accept or deny any surrender application. Rescue K-911's ability to accept animals is reliant upon available foster homes.

Today's date *

YYYY

Your full name: *

Your full address (Including City, State & Zip):

Your phone number: *

Your email address: *

Animal name (please include any previous names): *

This animal is a: *

Dog

Cat

Other:

Breed of animal: *

Age of animal: *

This animal is a: *

Male

Female

This animal has been spayed/neutered: *

Yes

Have you emailed rescuek911ks@gmail.com the most recent picture of this animal? *

Yes

If not, why?

Reason that you need to surrender your pet: *

Name of the vet clinic where this animal has been seen:
*

Did you email vet records to rescuek911ks@gmail.com?
*

Yes

If not, why?

Did you request records to be sent from your Vet to rescuek911ks@gmail.com?
*

Yes

Phone number of vet clinic this animal has been seen:

Date of last known dose of heart worm prevention given to this animal:
*

YYYY

What brand of heart worm prevention did you give to this animal?
*

Date of last known dose of flea/tick preventions given to this animal:
*

YYYY

What brand of flea/tick preventions did you give to this animal?
*

This animal does well around the following: *

Men

Women

Kids under 5 years of age

Kids over 5 years of age

Large dogs (60lbs and over)

Medium sized dogs (35-59lbs)

Small dogs (under 35lbs)

Cats

None of the above

Other:

Required

If this animal does not do well with any of the above, please explain:
*

The animal has the following training: *

Potty trained

Kennel trained

Leash trained

Knows commands

Litterbox trained

None of the above

Other:

Required

The animal has the following behavioral issues: *

Food or treat aggression- shows aggression toward humans or other animals when food or treats are present.

Possessive or protective over a family member

Leash reactive - shows aggression to other people or animals while on a leash

Separation anxiety - excessive barking, whining, or destroying items when left alone

Unprovoked aggression

Fearfulness towards humans

None of the above

Other:

Required

Please explain any of the above behavioral issues: *

Has this animal ever bit a human? *

Yes

If yes, please explain: *

* I have read the above information carefully and have filled out this surrender request honestly. I understand that omission of information and/or failure to answer all questions and sign the form can result in this request being declined. By signing this form, I hereby certify that I am the rightful owner/keeper/caretaker/custodian of this animal. I am relinquishing all rights to this animal to Rescue K-911 once the animal is in their possession. *

I have read the above disclosure

Required

E-SIGNATURE
*

THIS IS YOUR E-Signature. BY CHECKING THIS BOX YOU ARE IN AGREEMENT OF THE ABOVE DISCLOSURE.

Required

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