Animal Surrender Form

Please complete this form as fully as you can - fields marked * are required. Once complete hit the Submit button at the bottom of the page.
The information you provide here will help us to get to know your animal better and enable us to provide them with the best possible care when they arrive.

Animal Intake Type	Surrender
Section 1 - Your Details
Name *
Surname *
House No. and Street
Town
County
Postcode *
Contact Telephone No
E-Mail Address *
Section 2 - Animal's Details
Name
What type of animal are they?	R1 - Rabbit G1-Guinea Pig R2 - Rat H1 - Hamster G2 - Gerbil M1 - Mouse C1 - Chinchilla Other
Please specify
Breed (if known)
Gender	Male Female Unknown
Are they neutered?	NoYes
We will require proof of neutering - your vet will able to provide this
Age in years (estimated)
Are they vaccinated?	NoYes
When is their booster due?
We will require proof of vaccination - a photo of their vaccination card or vet record is sufficient for this
Please provide details of any health issues they have, including details of any medication they are on. This is to enable us to continue with their ongoing care with minimal disruption. We may request a copy of their records from your vet - we would always ask your permission first.
Health Notes
Please tell us anything you think would be useful to help us get to know them better - their personality, likes/dislikes, their current living environment (e.g. indoor/outdoor) or their life experiences (e.g are they used to children or other animals).
Notes
Section 3 - Surrender Details
How long have you owned your pet?
Where was your pet originally from?
Why do you need to surrender your pet?
How did you hear about us?	Word of mouth Google search Facebook Instagram Leaflet/Flyer Event Other
Please specify
Any other information that you'd like to add
Section 4 - Declaration
Please read and confirm that you understand the terms and conditions of surrender below, and then sign and date this form
*	I am the owner of this animal and have the legal right to surrender them
*	All of the information I have provided is complete and true to the best of my knowledge
*	I understand that by surrendering this animal I am releasing all rights to this animal to Fluffy Butts Rescue
*	I understand that once I have surrendered this animal I will not be entitled to ask for the animal to be returned to me
*	I understand that once this animal is surrendered Fluffy Butts Rescue will assume full responsibility for the animal's health and welfare whilst in their care.
Signed *	Clear
Date *

Registered Charity No: 1199101
Fluffy Butts Rescue is run entirely by volunteers and we rely on donations to care for our animals. We do not charge a fee when we take in surrendered animals, however any donation towards their future care would be appreciated
Our bank details are: Natwest Bank | Sort Code: 01-01-38 | Account No: 25436945