PET SURRENDER FORM

Please complete this form if you are wanting to surrender your pet to Belly Rub N Grub 501(c)3 animal rescue.

Please note that a Surrender Form must be filled for each surrendered pet.

Please note that if you adopted your pet from a rescue, you should contact them to see if they take their pets back. Most rescues want to and will take their pets back!

*Pet owner's information

First name

Last name

Address

Apt. No

City

State

Zip Code

County

Phone

Email

Relinquishment of Pet(s)

I hereby relinquish and release custody of my pet to Belly Rub N Grub 501(c)3 animal rescue located in Lancaster, California. Initials________

Type of Pet

Cat

Dog

Pet Gender

Male

Female

Current on Vaccines?

Yes - be read to provide records

No

*Pet Description

Pet's Name

Date of Birth

Month

Day

Year

Color and distinct markings of Pet

Hair Type

Hairless

Short Hair

Medium Hair

Long Hair

IMPORTANT NOTE:

You must provide a Spay and/or Neuter Certificate, in order to qualify for the Belly Rub N Grub 501(c)3 animal rescue Pet Surrender Program

Is the pet micro-chipped?

Yes - Please answer continue with micro-chip company questions.

No

Is the pet micro-chipped?

Yes - Please provide micro-chip number below.

No

Provide Micro-chip No

Vaccinations - please bring vaccine records

Yes, I will bring them with me

No

*Pet Health

For us to be prepared to provide your pet with the necessary care, please inform us of any special needs this pet may have or pre-existing medical conditions, such as, but not limited to:

*Special Considerations:

Please elaborate on your Special Consideration choices:

*Veterinarian Information

First Name

Last Name

Street Address, City, State, Zip & County

Phone

Email

Tell us more about the pet

Is your pet aggressive?

Yes

No

Are there any warning signs to the aggression?

Yes - if yes, please explain below

No

Is the aggression directed at a certain person or animal?

Yes - If yes please explain below

No

Please explain aggression and directed aggression

Have you consulted with a

Trainer

Behavioralist

Veterinarian

Other

*How long have you had your pet? When did you obtain?

Is there something we can do to help you keep your pet? If yes, please check what you need help with.

Printed name of owner surrendering pet.

Date and time

Month

Day

Year

Time

HoursMinutes

Consent - To help us not incur additional costs and more importantly to maintain the safety of our current rescue animals, as well as our own pets, BEFORE SURRENDERING YOUR PET, we require that they be tested at the vet/clinic for contagious and/or fatal diseases. Feline SNAP and Canine 4DX SNAP tests, Parvo test, as well as fecal test for Giardia, Coccidia and parasites. Pets must be spayed/neutered and up to date on vaccines (proof required). We can refer you to a low cost spay/neuter program!

We can’t take any chances with any diseases spreading and running rampant within our animal communities. Please BRING PROOF of NEGATIVE tests/results, along with vet/clinic information where tests were done for confirmation.

Thank you for your help and understanding.

The Fee to surrender a pet is $150 for each pet being surrendered. This fee is to help us with some intake costs, such as food, vetting and other necessities.

Signature

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