OWNER RELEASE FORM

Name: _________________________________________________________

Address: _______________________________________________________

City: ___________________________State: _______Zip:_______________

Phone: (H)____________________(W)________________Email: ____________

Cell: ___________________________

As owner of the below described pet, I hereby release my ownership of the below pet(s).  I understand this release does not entitle me to any financial compensation.

PETS NAME;_________________SEX:_______NEUTERED:______BREED:____________

DATE OF BIRTH OR AGE:________MICROCHIP #: ____________________________

PETS NAME;_________________SEX:_______NEUTERED:______BREED:____________

DATE OF BIRTH OR AGE:________MICROCHIP #: ____________________________

PETS NAME;_________________SEX:_______NEUTERED:______BREED:____________

DATE OF BIRTH OR AGE:________MICROCHIP #: ____________________________

BEHAVIOUR INFORMATION:

Housebroken?_________Good with Cats?________with other dogs?__________

with Children?__________Jumper, fence climber or bolt and runner?_________________

Has this dog EVER shown any signs of aggression or bit anyone?________if yes, please explain in DETAIL:_________________________________________________________

What is maximum time this dog has been left alone on a regular basis? _____________

Where kept when alone?  Crated: _____Free in house:_____ Other, Explain:___________

HEALTH HISTORY:

Vet Information: _____________________________________________________________

Date of last visit and reason: ___________________________________________________

Date of  DH2PP:___________ Rabies:__________ Bordetella: ________ Heartworm: _____

If over 5 years, Date of Last Dental: __________

Is this pet on any medication?_______If yes, please explain what condition is being treated

____________________________________________________________________________

Any other health issues? ________________________________________________________

What diet is pet currently on? __________________How often?_______________________

When was pet last groomed? ___________Groomers Name/No_______________________

PLEASE EXPLAIN IN DETAIL WHY YOU ARE RELEASING THIS PET:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In signing this form, I state that I am the only owner of the above pet(s) and as such relinquish all rights to this pet.  I state that the above information is true to the best of my knowledge and I give permission for my vet or groomer to release any and all information requested for the purpose of finding this pet a new home..  Further, I acknowledge that a $50 donation  is requested to help offset the care on my pet. 

SIGNED OWNER: ____________________________________DATE:_______________