Hiawatha Animal Humane Society

(hahumanesociety.org)

P.O. Box 215, Lake City, MN55041 – 651-448-0396

ANIMAL INTAKE/SURRENDER FORM – Must Accompany ALL Incoming Animals

NOTE:“Surrender Fee” is $40.00. Even though this may be a found animal, we are now taking overfrom you, the responsibility for its care and will immediately start spending a considerable amount of money on it. It is never possible for us to recoup all of the costs we incur prior to what we hope will be the animal’s eventua1 adoption, but this surrender fee will at least be a help.

(Please fill out this form as completely as you can.Must have info indicated in red!)

Name of Animal:______Dog/Cat/ Other:______Primary Breed:______

Secondary Breed:______Age or Date of Birth:______Gender:______Altered?:______

Size:_____ Condition:______Ever Bitten?______Primary color: ______Secondary color;______

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

GENERAL INFORMATION –

Where did you originally obtain this animal?______When?______

Reason for surrender?______

Good with kids? ______Good with other animals?______Has the animal been aggressive?______

(If so, explain):______

If it has ever bitten anyone, explain who, when, & circumstances:______Good with strangers?______Excessive bark, whine, meow?______Anxious or fearful?______

( If so, of what?):______

Housebroken / litter box trained? ______Declawed?______Good off leash?______

Been kenneled or crated?_____ Rides in vehicles?______Any health problems?______

(If so, what?):______

On any medications?______(If so, what?):______

Past Veterinary care provided by:______

Vaccinations – Rabies – Wormer, etc.? ______Please list and date:______Records available?______(If, so please provide.)

Food Preferences______Unique personality traits? ______Inside or Outside animal? ______Distinguishing marks?______

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

I hereby relinquish the above described animal(s) to the Hiawatha Animal Humane Society and at no time will I make claim against the Hiawatha Animal Humane Society. I understand that all decisions to place the pet for adoption or to be humanely put tosleep, are solely to the discretion of the personnel of the Hiawatha Animal Humane Society (all Minnesota Statutes and/or City Ordinances followed).

To the best of my knowledge this animal(s) has not bitten anyone in the last ten (10) days.

Signature:______Date:______

Printed Name:______

Street Address:______City::______State:______Zip:______

Phone: ______E-mail:______

If this is a surrender by a LAW ENFORCEMENT AGENCY, do you give us the authority to offer this animal for adoption?______Do you agree to pay the necessary pre-adoption costs incurred for this animal?______Do you also agree to all of the above provisions as outlined in this intake/surrender form? ______Signed by:______Phone #______

Accepted by:______Date:______revised 10-13-11