Owner/Guardian SURRENDER Contract Name DOB Phone # of Animals Surrendering Address City/State/Zip DOG s Name Breed Primary Color Pattern Age Gender: Male Female Neutered/Spayed? Y / N Animal ID (staff use only) By signing this contract, you, as legal owner of the animal, relinquish all rights to this animal and authorize The Humane Society of the Black Hills to request ALL medical records pertaining to the relinquished animal from your veterinarian. (name of veterinarian) The animal legally now becomes the property of The Humane Society of the Black Hills. The decision of the length of stay and its final disposition, including euthanasia, will be the sole decision of The Humane Society of the Black Hills. The Humane Society of the Black Hills is under NO obligation to return this animal to me during the period of its surrender and final disposition. Please circle the correct response: This animal HAS / HAS NOT bitten someone in the last 10 days. This animal IS / IS NOT sick at this time, as far as is known to me. Owner Signature Date
I Enjoy: I m Afraid Of: I m Described As: My Noise Level: Previous Training: Agility Being Left Alone Lap Loving High None Digging Children Curious Moderate Minimal Car Rides Loud Streets Friendly Low Some Climbing Loud Noises Mellow Fully Dog Park Men Active My Energy Level: Extensive Fetch Riding in Cars Playful High Hiding Uniforms/Hats Loner Moderate I Lived: Quiet Water Social Butterfly Low Indoors Running Women Submissive Outdoors Toys Loner Both Walking Commands Known: Swimming Bad Habits: Additional Comments: The Humane Society of the Black Hills requires a surrender fee for all animals. PLEASE READ AND SIGN THE FOLLOWING: I,, do hereby relinquish all rights of ownership of the above animal to become sole property of The Humane Society of the Black Hills on the day of, 20. I understand that the HSBH does not guarantee placemant of this animal or the length of time the animal will be held for adoption and his or her final disposition, including adoption or euthanasia, because this is at the sole discretion of the HSBH. Nor, will HSBH release any information about such final disposition. I understand that the HSBH is under no obligation to return this animal to me during the period between its surrender and its disposition. I understand the the HSBH has a policy that if I surrender an owned animal, I will not adopt another animal from this facility for a period of six months. I affirm that I have not taken this animal from another person without consent. I am the legal owner. To the best of my knowledge, this animal HAS / HAS NOT bitten in the last 10 days and IS / IS NOT sick. Signature: Date:
Dog s Name Pet Point # How long has this dog lived with you? Where did you obtain this dog? Please explain why you are relinquishing. Dog Health: What kind of food does your dog eat? Is your dog current on vaccinations? Y / N How does your dog behave at the vet? Any medical concerns? Dog Behavior & Habits: Is your dog primarily an indoor dog? Y / N If dog spends time outdoors, for how long? What is your dog s favorite game/activity? House Soiling Is your dog house trained? Y / N If not, please answer the following questions: In what circumstances does the house soiling take place? Any time When person is home When person is not home In front of the person In another room Right after coming back inside How often does this happen? Only 1 time Daily
Lived with Dogs Lived with Cats Lived with Children # # # Aggressive Towards Aggressive Towards Ages Bites/Snaps Bites/Snaps Aggressive Towards Cautious/Submissive Cautious/Submissive Bites/Snaps Tolerates Tolerates Cautious/Submissive Playful/Rambunctious Playful/Rambunctious Tolerates Fearful Fearful Playful/Rambunctious Friendly Friendly Fearful Chases Chases Friendly Chases I would recommend my dog live with (circle all that apply) : Dogs Cats Children For your dog s potential adopters: Please explain any behaviors/needs that the new adopters will need to be aware of, good or bad:
Aggression to People Does your dog show aggression to people? Y / N Who is the aggression directed towards and what is the response? Familiar Adults Unfamiliar Adults Children Under 6 Children 6 12 Men Women Comments: Aggression to Animals Has your dog been aggressive to other animals? Y / N If yes, please answer the following questions: Type of animals the dog is aggressive towards and response: Familiar Dogs Unfamiliar Dogs Familiar Cats Unfamiliar Cats Other Comments:
Dog Escape Does your dog try to escape out of your home/fence? Y / N If yes, please answer the following questions: How does the dog escape? Darts out the door Jumps/Climbs 6 ft. fence Jumps/Climbs 4 ft. fence Chews through fence Opens doors or gates Digs under fence How often does this occur? A few times Almost every day Always trying to escape How hard does the animal try to escape? Puts a great deal of effort into it Only if given a good opportunity Dog Destruction Has your dog been destructive in your home? Y / N If yes, please describe when it started/how often if happens and the type of destruction: