HSAC Pet Surrender Form

Please use this form to tell us about the pet(s) you wish to surrender. Please be honest and detailed in your responses.

How did you hear about us?
Your First Name (required) *
Your Last Name (required) *
Phone *
Cell Phone
Street Address (required) *
City (required) *
State (required) *
Zip Code
E-Mail Address
Please list the name(s), species, and gender(s) of the pet(s) you wish to surrender. *
Is/Are this/these pet(s) spayed/neutered? *	NoYes
What is/are the age(s) of this/these pet(s)? If the age is unknown, an estimate is okay.
Please describe how you acquired this/these pet(s).
How long have you had this/these pet(s)?
Why do you wish to surrender this/these pet(s)? *
To give this pet the best chance of finding a new home, please give us details about him/her. Include things like how the pet acts around children, strangers, other pets. How does the pet react to car rides? Leash walks (for dogs)? Baths? Energy level of this pet?
Please list any known medical issues this/these pet(s) has/have, including accidents, traumatic events (like car strikes), emergency vet visits, allergies, and genetic disorders. *
Surrender fees are used to help cover the cost of vetting surrendered pets. These costs include spay/neuter surgery, deworming, distemper vaccines, rabies vaccines, Bordatella vaccines for dogs/puppies, heartworm testing for dogs, FeLV/FIV testing for cats, medical treatment for injuries/diseases, food, flea/tick medicines, and staff salaries to care for the animal. The surrender fee for a dog/puppy is $30.00. The surrender fee for a cat/kitten is $25.00. Do you agree to pay the surrender fee?	NoYes
By surrendering a pet to HSAC, the animal becomes our responsibility. HSAC is under no obligation to return the animal to you, even if your circumstances change. Do you agree to this condition? *	NoYes

Humane Society of Adams County,Inc.