Surrender Request Form

Thank you for taking the time to complete our surrender request form. Completion of this form does not guarantee intake of your pet. A Hoppy, Healthy & Safe Volunteer will be in contact in 48 hours to notify you if the animal has been placed on our waitlist or if we are able to take your pet. There may be times that we refer you to an organization better suited for your pet.

First Name
Last Name
Address
Phone Number
Email
Confirm email
Name of Pet(s) you are looking to surrender
Species of Pet	Bird Camel Chicken Chinchilla Cockatiel Donkey Dove Ferret Gerbil Goat Goldfish Goose Guinea Pig Hamster Hedgehog Hermit Crab Horse Lizard Llama Mouse Owl Pig Pony Rabbit Rat Small Mammal Snake Terrapin Tortoise
Description of Animal(s)
Picture of animal *
Reason for Surrendering
Are You interested in learning more about our temporary foster care program?	NoYes
Does this animal have a history of any behavioral or medical issues?	NoYes
If yes, please describe
Where did you originally acquire your pet?
Any Other Information you would like us to know?
	I understand that completion of this form does not guarantee that HH&S will take my pet.
By signing below I confirm that I: am the owner of the animal and therefore have the rights to surrender this pet and that the above information is correct.	Clear