Intake Request

This intake request form should only be submitted by the animal's owner. Medical records are required, the animal must align with the LWHA mission, and we must have capacity to accept the surrender for approval.

This is only a REQUEST


Date *

Owner First Name *
Owner Last Name *

Email *
Primary Phone Number *
Back Up Phone Number *


Address *
City *
State *
Zip Code *



Are you the owner of this animal? * ONLY AN OWNER CAN SUBMIT THIS APPLICATION- if a dog has been in your possession for 10 days while you have actively searched for its home, then you are the legal owner
Animal's Name *
Species *
What is the animal's gender? *	Unneutered male Neutered male Unspayed female Spayed female
Animal's Breed (best guess is fine!) *
Animal's Age (best guess is fine!) *
Animal's Weight in Pounds (best guess is fine!) *
Animal's Color (best guess is fine!) *

Has this animal been on heartworm prevention for the last 6 months? *
When was their last heartworm test (dogs) or FELV/FIV test (cats)?
What was the result of their last heartworm test (dogs) or FELV/FIV test (cats)? *	Negative Positive Never tested
Any known medical issues *
Any known behavioral issues? *
Why does this animal need rescue? *

Which of the following applies to the animal you are trying to surrender? *	Not current on any vetting and not spayed//neutered ($100 surrender fee) Spayed/neutered, but not current on vaccines or any testing ($50 surrender fee) Current on vaccines and heartworm or FELV/FIV test, but not spayed/neutered ($100 surrender fee) Spayed/neutered, up to date on vaccines and testing ($0 surrender fee)

I understand that Long Way Home is a 501(c)(3) and operates solely on grants, public donations, and adoption fees. I understand that I will be required to show proof of records and pay any associated surrender fee based on those records for this animal. *	I agree I do not agree and will not submit this request


As the legal owner of the animal described below, hereby authorize LONG WAY HOME ADOPTABLES to take custody of said animal. I understand this animal may be placed in the care of other persons and/or facilities and that an attempt may or may not be made to place this animal for adoption. I also attest that to the best of my knowledge, the aforementioned animal has not bitten anyone at any point in their life. * Should the animal not be adoptable, or a suitable home not found, I understand the animal may be humanely euthanized. I further understand that after I release the animal to the custody of the LWHA, I will have no other contact with the animal in the future. I also agree to turn over all medical records I have for this animal to Long Way Home Adoptables including, but not limited to, vaccination records, surgical procedures, all provider notes, etc.