Owner Surrender Request Form

Please Note: Submission of this form does not guarantee immediate intake. Animals are accepted based on available space, staffing, medical resources, and urgency of need.

OWNER INFORMATION
First Name *
Last Name *
Address *
City *
State *
Zip Code *
Driver's License/ID Number *
Phone Number *
Email Address *
Confirm email
ANIMAL INFORMATION
Animal Name *
Species *	Cat Dog
Age (Approximate) *
Breed *	Airedale Terrier Akita Alaskan Malamute American Bulldog American Eskimo Dog American Staffordshire Terrier Anatolian Shepherd Australian Cattle Dog/Blue Heeler Australian Kelpie Australian Shepherd Australian Terrier Basenji Basset Hound Beagle Belgian Shepherd Dog Sheepdog Belgian Shepherd Malinois Bernese Mountain Dog Bichon Frise Black and Tan Coonhound Black Labrador Retriever Black Mouth Cur Bloodhound Bluetick Coonhound Border Collie Border Terrier Borzoi Boston Terrier Boxer Boykin Spaniel Briard Brittany Spaniel Bullmastiff Bull Terrier Cairn Terrier Cane Corso Mastiff Carolina Dog Catahoula Leopard Dog Cattle Dog Cavalier King Charles Spaniel Chesapeake Bay Retriever Chihuahua Chinese Crested Dog Chocolate Labrador Retriever Chow Chow Clumber Spaniel Cockapoo Cocker Spaniel Collie Coonhound Corgi Dachshund Dalmatian Doberman Pinscher Domestic Long Hair Domestic Medium Hair Domestic Short Hair Dutch Shepherd English Bulldog English Cocker Spaniel English Coonhound English Pointer English Setter English Shepherd English Springer Spaniel English Toy Spaniel Eskimo Dog Extra-Toes Cat (Hemingway Polydactyl) Field Spaniel Finnish Lapphund Finnish Spitz Flat-coated Retriever Foxhound Fox Terrier French Bulldog German Pinscher German Shepherd Dog German Shorthaired Pointer German Wirehaired Pointer Golden Retriever Gordon Setter Great Dane Greater Swiss Mountain Dog Great Pyrenees Greyhound Havanese Hound Husky Ibizan Hound Irish Setter Irish Terrier Irish Water Spaniel Irish Wolfhound Italian Greyhound Italian Spinone Jack Russell Terrier Keeshond Kerry Blue Terrier Labrador Retriever Lakeland Terrier Lancashire Heeler Leonberger Lhasa Apso Maltese Manchester Terrier Mastiff Miniature Pinscher Mixed Breed Mountain Cur Mountain Dog Newfoundland Dog Norfolk Terrier Norwegian Elkhound Norwegian Lundehund Norwich Terrier Nova Scotia Duck-Tolling Retriever Old English Sheepdog Otterhound Papillon Patterdale Terrier (Fell Terrier) Pekingese Petit Basset Griffon Vendeen Pharaoh Hound Pit Bull Terrier Plott Hound Pointer Polish Lowland Sheepdog Pomeranian Poodle Portugese Podengo Portuguese Water Dog Pug Rat Terrier Redbone Coonhound Retriever Rhodesian Ridgeback Rottweiler Saint Bernard St. Bernard Saluki Samoyed Schipperke Schnauzer Scottish Deerhound Scottish Terrier Scottie Setter Shar Pei Sheep Dog Shepherd Shetland Sheepdog Sheltie Shiba Inu Shih Tzu Siamese Siberian Husky Silky Terrier Skye Terrier Smooth Fox Terrier Somali Spaniel Spitz Staffordshire Bull Terrier Terrier Thai Ridgeback Tibetan Mastiff Tibetan Spaniel Tibetan Terrier Toy Fox Terrier Treeing Walker Coonhound Unknown Vizsla Weimaraner Welsh Corgi Welsh Springer Spaniel Welsh Terrier West Highland White Terrier Westie Wheaten Terrier Whippet White German Shepherd Wire-haired Pointing Griffon Wirehaired Terrier Yellow Labrador Retriever Yorkshire Terrier Yorkie
Sex *	Male Female
Spayed/Neutered *	NoYes
Approximate Weight
Microchipped *	NoYes
How long have you had this animal? *
Where did you get this animal? *	Breeder Shelter / Rescue Family / Friend Found as a stray Born in my care Other
If other, please explain.
REASON FOR SURRENDER
Primary Reason for Surrender *	Financial hardship Moving Landlord / housing restriction Owner health issue Family changes Too many animals Behavior concerns Medical concerns Cannot provide care Stray originally taken in but cannot keep Other
Please explain your situation *
Is there a deadline by which the animal must leave your home? *	NoYes
If yes, what is the deadline?
HEALTH INFORMATION
Has this animal been seen by a veterinarian? *	NoYes
Veterinary Clinic Name
Is this animal current on vaccines? *	Yes No Unknown
Any known medical conditions?
Is this animal on any current medications?
Is the animal currently sick, injured, or in distress? *	NoYes
If yes, please explain.
BEHAVIOR INFORMATION
Has this animal ever bitten a person? *	Yes No Unknown
If yes, please explain what happened and when.
Has this animal ever bitten another animal? *	Yes No Unknown
If yes, please explain what happened and when.
Has this animal shown aggression toward people? *	Yes No Unknown
Has this animal shown aggression toward other animals? *	Yes No Unknown
This animal has lived with: *	Adults Children Dogs Cats Small animals No other animals Unknown
Please check all that apply. *	Housebroken Litterbox trained Crate trained Leash trained Indoor only Outdoor only Indoor / outdoor Escape artist Destructive Fearful Friendly Shy High energy
REHOMING / FOSTER OPTIONS
What rehoming efforts have you already made? *	Friends / family Social media Rehoming websites Contacted rescues Contacted breeder Contacted veterinarian None yet
Would you be willing to foster this animal through DCHS until space is available? *	Yes No Maybe
If yes or maybe, how long could you continue caring for the animal?
If yes or maybe, how long could you continue caring for the animal?
PHOTOS / RECORDS
Upload photo of animal *
Upload vet records
Upload bite records, animal control reports, or other relevant documents
REQUIRED ACKNOWLEDGEMENTS
Please acknowledge each statement by checking each box. *	I understand that submitting this form does not guarantee that DCHS can immediately accept my animal. I understand that DCHS schedules owner surrenders based on available space, staffing, medical resources, and urgency. I understand that I should not bring this animal to DCHS unless I have been contacted by staff and given an intake appointment. I certify that I am the legal owner of this animal or have authority to surrender this animal. I understand that if this animal is formally surrendered to DCHS, ownership transfers to DCHS. I understand that once surrendered, DCHS may determine the outcome of the animal, including adoption, transfer, foster placement, rescue placement, or humane euthanasia.
By signing my full name, I certify that the information provided is true and accurate. *	Clear

Reminder: Please do not bring your pet to the shelter unless you have been contacted by DCHS and given a scheduled appointment or other instructions by staff.