Humane Society of Burnett County

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Animal Surrender Form

ANIMAL SURRENDER
HSBC is unable to accept same day surrenders. Surrender request approval is based on available space,
existing medical or behavioral conditions and suitability of your animal to thrive in a shelter environment. A
fee of $25 per cat and $50 per dog is required to assist in the cost of care while awaiting adoption.

Email

This field is for validation purposes and should be left unchanged.

Owner Name(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

DOG CAT(Required)

DOG

CAT

Animal Name(Required)

Breed(Required)

Age(Required)

Sex(Required)

Spayed/Neutered

YES

NO

Vaccines current?

YES

NO

Color

Veterinarian

Vet Phone

Reason for surrender:(Required)

Medical needs of animal

Medical needs of owner

Animal behavior problem

Moving

Allergies

Cost of care

Death of owner

Other

Please explain in detail

About your pet:

Interactions with dogs:

Playful

Tolerant

Easygoing

Fearful

Aggressive

Unknown

Other

Interactions with cats:

Playful

Tolerant

Easygoing

Fearful

Aggressive

Unknown

Other

Interactions with kids:

Playful

Tolerant

Easygoing

Fearful

Aggressive

Unknown

Other

Check all that apply

House/litterbox trained

Leash trained

Crate trained

Social butterfly

Destructive

Anxious/timid

Resource guarding

Fearful of men

Fearful of strangers

Runs away

Any other information that will help us find an appropriate home:

PLEASE READ CAREFULLY BEFORE INITIALING & SIGNING

I hereby certify I own this animal and have authority to hereby transfer and release ownership of said animal to the Humane Society of Burnett County, Inc.(Required)

I hereby certify I own this animal and have authority to hereby transfer and release ownership of said animal to the Humane Society of Burnett County, Inc.

I understand that HSBC has full responsibility for the future care and placement of this animal.(Required)

I understand that HSBC has full responsibility for the future care and placement of this animal.

I understand that HSBC will give me no information on the said animal in regard to the outcome of the animal.(Required)

I understand that HSBC will give me no information on the said animal in regard to the outcome of the animal.

I understand if for some reason I would like the animal back, I will have to undergo the standard adoption procedure, including application and payment of the current adoption fees(Required)

I understand if for some reason I would like the animal back, I will have to undergo the standard adoption procedure, including application and payment of the current adoption fees

To the best of my knowledge, has this animal bitten or scratched anyone in the past ten days?(Required)

YES

NO

Signature of Owner