ARF Animal Surrender Intake Form

ARF Animal Surrender Intake Form

Please provide the following information so we can determine the best decision for the animal.

Contact Information

Name
Street Address
City ST ZIP Code
Home Phone
Work Phone
E-Mail Address

Animal Information

Animal’s Name / Cat or Dog – Circle One / Purebred or Mix Circle One
Coat Color / Age / Sex
Is animal spayed or neutered? ___ Y / ___ N / Is pet microchipped? ___ Y / ___ N
Please provide number and any paperwork you have
Is animal good with kids? ___ Y / ___ N / Is animal good with dogs? ___ Y / ___ N
Is animal good with cats? ___ y / ___ N

Veterinary Information – Please document information in right-hand column

Veterinary Name:
Veterinary Address:
Veterinary Phone #:

“Other” Animal Information – Please answer in the right-hand column.

Have you ever given up a pet in the past for any reason?
__ Yes / __ No / Please explain
Have you put an animal to sleep (euthanized)
__ Yes / __ No / Please explain

General Questions

Any obedience training? If so, please specify the commands he/she knows.
Crate trained?
Housebroken?
Is the animal on any medication?
What amount of exercise does the pet get daily?
Do they walk well on a leash?
Where was the dog during the day while you were at work?
Where was the dog kept at night?
Where was the dog when you were home?
Why are you giving up the animal?
Please list any other information about the animal that would be useful for our foster homes or potential new adoptive families to know. Please list both good and bad things that we should know.

Agreement and Signature

By signing below, 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.” I hereby surrender any and all property rights to the animal. I certify that no other person has a right of property to the animal. I also hereby certify that the animal has/has not [circle one] bitten or scratched a human or another animal within the past 10 days. 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.
Name (printed)
Signature
Date

Please Return Application To:

Please email this document to: . and contact ARF at 630-200-3828. You will need approval from ARF prior to surrendering and will need to make an appointment to surrender the animal.

1/4/2012