Animal Surrender
Personal
Info.
Name: Date:
Address: City:
State: Zip: Phone:
E-mail:
Animal
Info. (if puppies, list # of puppies)
Name: Age: DOB:
Mother Breed: Father Breed:
Place Dog Obtained: Date Obtained:
# of DHPP:
Date of last DHPP:
Date Spayed / Neutered: Date of Rabies:
Descriptive Items (color of
coat, etc…):
Please explain reason for
surrendering animal:
RELEASE: I declare that I am the legal owner of the animal described above, or that I represent an agency or individual that has legal title to this animal. As such, I hereby relinquish all rights to the animal described above to Viola Valley Dogs, Inc. I understand that upon transferring this dog to Viola Valley Dogs, Inc. that Viola Valley Dogs, Inc. becomes the sole owner of the dog. I will make no attempt to reclaim the dog, although I am welcome to contact Viola Valley Dogs, Inc. to see how the dog is doing. I fully grant Viola Valley Dogs, Inc. the right to give the dog any medical treatment deemed necessary and to place the dog in a good adoptive home. Should a veterinarian determine the dog is too ill to be treated or that the dog is vicious, or should the Viola Valley Dogs, Inc. Board determine that the dog's quality of life is compromised due to behavior problems, I give Viola Valley Dogs, Inc. the right humanely euthanize said dog. I release Viola Valley Dogs, Inc. from all liability concerning said animal. Viola Valley Dogs, Inc. will make every attempt to provide adequate foster care but is not liable for any action of said animal or accident sustained. I hereby state that I am giving up this dog of my own free will. To my knowledge the animal has not bitten anyone in the past ten days.
(Signature)
(Witness)
(Printed
Name) (Printed
Name)
There is a $10 fee per puppy, $50 per adult male, and $100 per female surrendered to cover part of the cost of
food.
Fee Amount: Payment
Type: Check #:
Donation Amount: Payment Type: Check #: