Animal Name *
Pet Species *
Dog
Cat
Other
Breed *
Sex *
Male
Female
Age and/or date of birth *
Has the animal been neutered? *
Yes
No
Unknown
Is the animal up to date with its annual vaccinations? *
Yes
No
Unknown
Has your pet been diagnosed with any type of illness and/or injury? *
No Yes
If you answered yes to previous question, please list diagnosis and/or all medication prescribed for pet
Where did you get your pet? *
Kodiak Animal Shelter
Breeder
Found Stray
Pet Store
Offspring From Pet
Relative
Friend
Abandoned
Other
Why are you surrendering your pet? *
Moving
Allergies
Behavior Issues
Can't Afford
Don't have enough time
New Baby
Doesn't get along with other pets
Too many pets
Owner passed away
Landlord
Divorce
Don't want anymore
Other
Does the animal have any behavioral issues we should know about? *
No Yes
What behavior issues is your pet experiencing? Please give us as much information as possible about your pets behavior issues
Has the animal ever bitten a person? *
No Yes
Has the animal ever bitten another animal? *
No Yes
Has the animal lived with children? *
No Yes
If yes, do you recommend placing pet in a home with children? *
No Yes
Has the animal lived with dogs? *
No Yes
Has animal lived with cats? *
No Yes
Do you recommend placing pet in a home with other animals? *
Yes, both dogs & cats
Dogs Only
Cats Only
No other pets
Is the animal used to men and women? *
Yes, Both
Woman Only
Men Only
Is the animal housetrained? *
No Yes
Is the pet crate trained? *
No Yes
Will the animal give up toys when commanded to? *
Yes
No
Unknown
Does not apply
Where does the animal sleep? *
Crate
Pet Bed
In Bed
Outside
Wherever they like
Is the animal destructive when left alone in the house? *
No Yes
Does your animal return when called whilst off the lead? *
No Yes
How does your animal behave at the vet? *
Behaves well
Nervous
Needs to be muzzled
Needs to be medicated
Unknown
How does your animal react to grooming and nail trims? *
Good | Does not like | Unknown
No Yes
What is the animal's reaction if you approach it when it is feeding? *
No issues
Growls
Snaps or attempts to bite
Do not feed around other animals
Please describe your animal's feeding regime - brands of food, scraps, dry or tinned, flavours, feeding times and quantities. Any dislikes? *
Does your animal know any commands? check all that apply *
Sit Down Come Shake Drop It None
Person providing information *
Owner
Agent
First name *
Last name *
Address *
Phone number *
Email address *
I acknowledge my understanding of, and agreement with the following terms and conditions that govern the relinquishment of the above described pet
If the animal is of suitable health and temperament, it will be placed in the Humane Society's adoption program: *
No Yes
The Kodiak Animal Shelter is a "no kill" shelter for "friendly, adoptable animals. If this animal does not pass the health and/or behavioral screening at any time during the pet's stay, we may have to euthanize. This means that the animal will be put to death in the most humane way possible. It is extremely rare that we have to euthanize a pet, but in extreme circumstances the health and quality of life of the pet is taken seriously: *
No Yes
I understand that I can contact the Kodiak Animal Shelter at any time to check the status of the pet that is being surrendered. I also understand that it is my responsibility to update my contact information with the Kodiak Animal Shelter.
I herby release the Humane Society of Kodiak and its employees, staff, agents and/or representatives from any claims or demands that I have, or my have, that (a) may be connected with the above described pet; (b) may arise out of the Humane Society's care of the above described pet; or (c) may arise out of the Humane Society euthanizing this pet.
Signature *
Clear
Date *
