North East Washington Animal Protection League 1381 Little Twin Lakes Road Colville, Washington 99114 509-684-4421 ANIMAL SURRENDER FORM North East Washington Animal Protection League (NEWAPL) Date _________________ Intake # _____________________Species______________________ Animal Name_________________________________________ Age _____________________ Breed___________________________________ Sex_________ Spayed/Neutered: Yes No Has your pet bit or scratched a person in the last ten (10) days? ___Yes ___No Date _________ If yes, who (name) _______________________________ In what city?__________________ SURRENDER HISTORY Why are you surrendering your pet? Please provide as much info as you can; it helps us better care for your pet. If we could help you resolve issues, would you be interested in keeping the animal? ___Yes ___ No Would need______________________________________________________ How long have you owned the animal? __________How many homes has the animal had? ___________ Where did you get the animal? ___NEWAPL ___Another Shelter ___Pet Store ___Newspaper ___Breeder ___Friend/Relative ___Found as a stray ___Born in my home ___ Other________ Does your animal have: Tattoo Microchip ___Yes ___No ___ Not Sure MEDICAL INFORMATION Has your animal been to a veterinarian? ___ Yes ___ No ___ Not sure Veterinarian____________________________ City & State ____________________________________ Is he current on vaccinations? ___Yes ___No ___ Not sure Has your pet been hit by a car, injured, or required other surgery? ___Yes ___ No ___ Not sure If yes, please explain____________________________________________________________________ Has your pet been diagnosed with and/or treated for any of the following: (Check all that apply) ___Allergies ___Asthma ___Epilepsy/seizures ___Urinary tract infection ___Diabetes ___Cancer ___Upper respiratory infection ___Thyroid disease ___Organ failure ___Parvo ___Tumors ___Bloat ___Arthritis ___Mange ___Heart Murmur ___Other (please detail) ______________________________ GENERAL PERSONALITY How would you describe your animal most of the time? (Check all that apply) ___Very active ___Couch potato ___Talkative ___Quiet ___Playful ___Friendly to family ___Escape artist ___Shy to family ___Friendly to visitors ___Shy to visitors ___Affectionate ___Fearful ___Independent ___Fearless ___A clown ___Aloof ___Withdrawn ___Solitary ___Loves kids under 5yrs ___ 5-12 yrs ___12-18yrs ___No patience with kids ___ Not sure how he is with kids Good with men? ___Yes ___No ___Not sure Good with women? ___Yes ___ No ___Not sure Good with cats? ___Yes ___No ___Not sure Good with dogs? ___Yes ___No ___Not sure What is the animalÕs favorite toy? _________________________________________________________ What brand of food has he been eating? ________________________________________ Canned/Dry Where does he like to sleep? _____________________________________________________________ What, if anything, is he afraid of? _________________________________________________________ What, if anything has your animal been aggressive towards? ____________________________________ DOG How is your dog with livestock? ___ Good ___Has worked livestock ___Chases ___Has killed ____Not Sure Has he had any obedience training? ___Yes ___No ___Not sure If he has been trained, what kind of training was it? ___Punishment ___Positive reinforcement ___Food/treat rewards ___ Clicker ___Leash correction ___E-collar ___Other _________________ Is he crate trained? ___Yes ___No What commands does the dog know? ___Sit ___Stay ___Down ___Off ___Heel ___Come Other ________________________________________________________________________ Does he come when called? ___Yes ___ No Has he been used for hunting? ___Yes ___No Does he jump fences? ___Yes ___No If yes, how high? _________ Does he dig under fences? ___Yes ___ No Is he house trained? ___Yes ___ No ___Somewhat If somewhat, does he ___lift his leg? ___urinate when heÕs excited? ___urinate in his crate? ___have accidents if left too long? ___ cannot be trusted alone? ___other______________________ How does he let you know when he/she has to go to the bathroom? ______________________________ Where is he kept during the day? _________________________ At night? ________________________ Has he ever bitten a person? ___Yes ___ No If yes, did it break the skin? ___Yes ___No Was animal control involved? ___Yes ___ No If yes to any, please explain in detail:___________ _____________________________________________________________________________________ _____________________________________________________________________________________ Is there anything else a future owner should know about your pet? CATS ___Barn Cat ___Lap Cat ___Loves to be inside only ___Loves to go out sometimes ___Outdoor only ___More like a dog ___Great Mouser ___Will hunt birds when outside Is your cat declawed? Yes/No ___ Front ___Back ___All Four Feet If yes, when was it done? ___ as a kitten ___as an adult ___acquired declawed Is he litter box trained? ___ Yes ___No What type of litter is he used to? ________________________ Has he ever urinated outside the litter box? ___Yes ___No If yes, please explain ________________ Is there anything else a future owner should know about your pet? _______________________________ _____________________________________________________________________________________ Surrender Agreement: I certify that I am the owner of or have the authority to surrender the animal described to NEWAPL. I hereby relinquish all rights of ownership and any right to information on the disposition of the animal described to NEWAPL. I also authorize the release of any veterinary records regarding the animal. I certify that to the best of my knowledge I have disclosed all of the information about the animal concerning health, behavior, history and anything else that may effect the safe placement of the animal in a new home. If I wish to reclaim this animal from NEWAPL, I agree to undergo the same adoption requirements and approvals as a new owner and agree to reimburse NEWAPL for its expense of caring for the animal and any expenses associated with preparing and holding the animal for adoption. Signed_______________________________________________ Date_________________________ Printed Name__________________________________________ Phone_______________________ Address_____________________________ City_____________ State_______ ZIP_____________ If you are able, please consider making a donation now to help us care for your pet during his or her stay with us. NEWAPL spends an average of $350 per animal to cover food, shelter, medical and other expenses. Thank you for bringing your pet to the shelter Ð we know it was a tough decision for you, and we want you to know that we will take good care of him/her.