Rehome a pet Surrender a Pet Download/Print the PDF if you choose not to fill out below Surrender a Pet "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Perry Animal Welfare Society - Perry County Humane SocietySurrender Release FormOwner InformationName*Telephone*Email Address* Address*City*State*ZIP code*Animal InformationReason for giving up dog/cat*Name of dog or cat*Animal type* Dog Cat Sex* Male Female Unknown Spayed/Neutered* Yes No Unknown Birth DateEnter the birth date if known. If uncertain, enter an approximate date or Unknown.How long has the dog/cat lived with you?*Does this dog or cat have any health conditions?*Enter known conditions, None, or Unknown.This dog/cat is (check all that apply): Inside dog/cat Outside dog/cat Chained outside Fenced yard Runs loose Crate trained Housebroken Mean dog/cat Sweet dog/cat Timid Aggressive Loves cats Hates cats Loves dogs Hates dogs Picky eater Eats anything Likes grooming Hates grooming Rides good in car Rides bad in car Runner Walks off leash What bad habits does this dog/cat display?*Enter details, None, or Unknown as appropriate.What are the dog or cat’s best qualities?*Enter details, None, or Unknown as appropriate.What training has this dog/cat had?*Enter details, None, or Unknown as appropriate.Behavior and Incident HistoryThe following questions retain the dog-specific wording of the source document. For a cat, select Not applicable where appropriate.Has the dog ever chased or attempted to attack or bite a person or animal?* Yes No Unknown Not applicable Describe the incident(s) in which the behavior occurred.*Has the dog ever bitten a person or animal?* Yes No Unknown Not applicable Describe the incident(s) in which the behavior occurred.*Has the dog ever seriously injured or killed a person or animal?* Yes No Unknown Not applicable Describe the incident(s) in which the behavior occurred.*Has the dog previously been designated a nuisance, dangerous or vicious dog?* Yes No Unknown Not applicable Indicate the designation that was assigned, the date of designation, and in which county or city the designation was made.*Veterinary InformationVeterinarian NameVeterinarian TelephoneVeterinarian AddressVeterinarian CityVeterinarian StateVeterinarian ZIP codeVaccinations, Tests, and IdentificationEnter the date of the last vaccination or test where known. You may enter Unknown or Not applicable.Date of last: DHLP-PDate of last: Parvo/CoronaDate of last: BordetellaDate of last: RabiesDate of last: Heartworm testDate of last: Fecal ExamRV#License #Current Medications and HealthCurrent medications: HeartwormCurrent medications: OtherAny health problems*Enter details, None, or Unknown.Surrender Release and Owner SignatureI, the undersigned, certify ownership of the dog/cat described above. I certify that this dog has not bitten any person or animal within the last 10 days, and has not been exposed to rabies. I give complete ownership of the dog/cat to Perry Animal Welfare Society - Perry County Humane Society releasing its representative from all liabilities of said dog/cat.Owner acknowledgment* I have read and agree to the ownership certification and surrender release above. Owner Signature*Your NameYour NameYour NameYour NameSign in the box using your mouse, touchpad, or touchscreen.Date*
