K9 Relinquishment Form Date Owner Name Mailing Address (include city, state, and zip code) Physical Address (include city, state, and zip code) Home Phone Cell Phone Email Pet Name Age Weight Color Breed Gender Male Female Spayed / Neutered Yes No Up to date on vaccinations Yes No I'm not sure Microchipped Yes No I'm not sure Last Vet Visit Name of vet Phone number of vet Address of vet Why are you giving this dog up? (be specific) Where did you get this dog? How long have you had this dog? Is this dog house trained? Yes No Does he / she use the following (check all that apply): Doggie door Signals If signals, what type of signals should we look for? Where does this dog usually reside? Indoors Indoor / Outdoor Outdoor Garage Crate How many dogs do you have? None 1 2 3 4+ How many cats do you have? None 1 2 3 4+ How many other pets do you have? None 1 2 3 4+ Does this dog get along with kids? Yes No I'm not sure Behavior around kids? Friendly Playful Tolerant Afraid Shy Does this dog get along with cats? Yes No I'm not sure If no, please explain Does this dog get along with dogs outside the household? Yes No I'm not sure If no, please explain Is the dog destructive in any way? Yes No If yes, explain Describe the dog's behavior most of the time Has this dog ever shown signs of aggression? Yes No If yes, explain Has this dog ever bit a person? Yes No If yes, explain Has this dog ever bit another animal? Yes No If yes, explain Where is the dog's favorite sleeping place? How many hours per day is the dog left alone? 1-4 hours 4-8 hours More than 8 hours Does the dog utilize a dog house? Yes No Favorite toy or game? Is the dog on a special diet? Yes No How many times per day is the dog fed? Once Twice Three times Free feed What time is feeding? (check all that apply) Morning Afternoon Early evening Free feed How much food is given each feeding? What brand of dog food do you feed? Wet or dry food? Wet Dry Both Anything else you would like to share to assist us in finding the perfect home for your pet? I, the undersigned, do hereby give my consent and permission for the Mountains’ Humane Society to take possession of the animal described herein for the purpose of placing it for adoption with another party. I further declare that I am the lawful owner of said animal and have disclosed the medical history and any behavioral abnormalities with Mountains’ Humane Society or its agent(s). I further affirm that I relinquish any further claim of said animal and release Mountains’ Humane Society, including its officers, directors, volunteers and employees of all liability involved in this transfer of ownership. I understand that there is a $100 cash per pet relinquishment fee that I will be responsible for. Signature(required) Date(required) Submit Δ
Mountains' Humane Society Pet Rescue