First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone*

What type of animal are you requesting to surrender?
Choose one: Dog Cat Other

Breed*

What is your animal's name?*

Is your pet spayed/nuetered?*
Choose one: Yes No

What is the pet's gender?
Choose one: Male Female

What is the pet's age?*

What is the pet's approximate weight?*
Choose one: 0-5lbs 5-15lbs 15-35lbs 35-50lbs 50-75lbs 75-100lbs 100lbs+

Is the pet currently vaccinated?*
Choose one: Yes No

How would you describe the dog?*
Choose one: Family Dog Dog for Adults Only 1 person Dog Watch Dog

How long has the pet been owned?*

Is the dog house broken?
Choose one: Yes No

Has the animal ever bitten?*
Choose one: Yes No

If yes, please describe. Please include who/what the pet bit (ie other animal, adult, child, etc)

Is the dog destructive when left alone?*
Choose one: Yes No

If yes what are the behaviors? (Check all that apply)

What behaviors does the dog display when unsupervised outside?

How does the dog play?*
Choose one: Roughly Politely

Does the dog display fear behavior?*
Choose one: Yes No

If yes, what seems to be the cause of the fear behavior?

Please describe the pet's personality.*

Please describe any health issues the pet has or may have. *

Has the pet displayed any recent changes in behavior, activity or condition?*
Choose one: Yes No

If yes, please check any that apply

Why are you interested in surrendering the pet?*

•I understand by surrendering the dog to Riverview Rescue, I would be relinquishing any and all ownership rights. • I understand that by surrendering my dog I will be unable to determine its final disposition. I understand that Riverview Rescue will not sell animals for research and will not euthanize animals unless they are deemed unadoptable for health or demeanor reasons. Euthanization is always the last option after trying all other avenues. • I agree that neither Riverview Rescue nor its employees will incur any obligation to me as a result of any disposition. • I understand that if I wish to reclaim this dog, Riverview Rescue may or may not allow reclamation and I will be liable for all expenses, direct and indirect, incurred by the Rescue while in the custody of the Rescue. • I assert that this dog is my property and has not been taken by another owner with or without his/her permission. *
Choose one: Yes No

Please enter your name and today's date certifying the above information to be true and correct.*