Surrender Form | Medfield Animal Shelter

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

How did this pet come into your care?*

I'm the owner

Relinquished to rescuer by owner

Found as a stray by rescuer

Relinquished to Animal Control

Found as a stray by Animal Control

Surrendered to Animal Control

Found as a stray by an individual

Name of Organization/Rescue*

Did you notify animal control you found this pet? (MDAR requires ACO notification before we accept a stray)*

Location pet was found*

Reason pet was surrendered to you*

Why did the owner surrender their pet to you?

Name*

First Last

Address*

City*

State

Email*

Enter Email Confirm Email

Best phone # for reaching you?

Name of Original Owner*

First Last

Address of Original Owner*

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

Pet Information

What type of pet do you need to give up or transfer?*

What breed or breed mix is your dog?*

Name of Pet

Pet's age*

Sex*

Male

Female

Reason for surrender?*

How long has the pet been in your care?*

Has this pet lived with other animals*

Yes

I don't know

Please tell us about the other pets and how your pet gets along with them

Has this pet lived with children?*

Yes

There are children that visit frequently

I don't know

Is this pet housebroken?*

Yes

Working on it but still has accidents

If there are children, is this pet comfortable wiith them?

Does this pet have any health or behavioral issues?*

Does this pet allow handling and petting*

When was this pet last seen by a vet?*

Is this pet up to date on rabies vaccination?*

Yes

I don't know

Is this pet up to date on distemper vaccination?*

Yes

I don't know

Name and Contact Information of the vet that last saw the pet

Is this pet spayed or neutered?*

Yes

Not sure

Is this dog on heartworm preventative?*

Yes

Date last heartworm preventative given

To the best of your knowledge has this animal bitten or shown potential to bite in the past?*

Yes

I don't know

When do you need to surrender this pet?*

The Medfield Animal Shelter is small and has limited capacity so we don't always have space to take in new pets.

What type of food does this pet eat and how much*

Tell us more about this pet and what type of home he/she would thrive in*

(I/we) acknowledge and agree that if the Medfield Animal Shelter agrees to take in the above-described pet, then (I/we) hereby relinquish any and all legal and other rights of ownership of the pet. (I /we) represent that (I/we) are the sole lawful owner(s) of, and have the complete and sole right to transfer and deliver, the pet; and that the pet is free and clear from claims of ownership or other rights of any kind whatsoever by any other person or entity. (I/we) understand that the Medfield Animal Shelter will act in the best interest of the pet in its care and placement. By assuming ownership, the Medfield Animal Shelter reserves all rights in regard to making all decisions in regard to the pet's care, placement, and medical treatment.

(I/we) acknowledge and agree that (I/we) will take back the pet (at the sole discretion of the Medfield Animal Shelter), if the pet fails to pass the Medfield Animal Shelter’s intake evaluation or temperament/handling test, or the pet exhibits undisclosed medical or behavioral issues, either during the intake exam or the first week the pet is at the Shelter..

Signature

Date

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Surrender Request

Pet Information