Rehome – K9 Hope Broker

Name

Street Address

City

State

Zip Code

Phone

What is your preferred method of contact?

How long have you owned your dog?

Animal Name

Breed/Color

Age /DOB

Is the Dog Altered (spayed/neutered)?

Is the Dog microchipped?

Where did you get your pet?

If from a breeder, rescue group, humane society or other shelter, have you tried contacting them to see if they can take the animal back into their facility?

If yes, what was their response?

Has your pet seen a vet?

Yes No I don't know

If yes, Please provide Vet clinic name, address and contact info:

Date of last visit:

Does your pet need muzzle/sedation at vet?

Yes No I don't know

Describe any major illnesses and surgeries:

Has your pet ever bitten?

If yes, did it break the skin?

Date of last bite:

Under what circumstances will your pet bite?

Housetrained:

Housetrained details:

Special Needs – Behavior: (Choose any applicable)

Special Needs – Medical: (Choose any applicable)

Historical Environment: (Where does your animal usually stay)

Primarily Indoor Primarily Outdoor Both Indoor/Outdoor Primarily Garage/Basement

Special Needs Comments:

Allergies:

Medications/Dosage:

Lived with or interacted with other dogs?

Yes, we have dogs in our home No dogs in the home/No interaction Aggressive/Do not place with dogs

List breeds (if any)

If you selected any negative behaviors above, please explain:

Lived with or interacted with other animals/wildlife?

Yes, we have other animals at our home No other animals or wildlife at the home/No interaction Aggressive/Do not place with other animals

List breeds (if any)

If you selected any negative behaviors above, please explain:

Lived with or interacted with other people?

Yes, we have other adults in our home Yes, we have children in our home Yes, we have adults and children in our home No people in the home/No interaction Aggressive/Do not place with children

Ages of people in your home (check all that apply)

Children under 5 years Children 6-12 years Teenagers 13-19 years Adults 20+

If you selected any negative behaviors above, please explain:

Activity Level

Low Moderate High

Vocalization Level

Low Moderate High

Off Leash, My pet is:

Completely Reliable Somewhat Reliable Not Reliable/Unknown

My pet escapes fences:

Yes No Unknown

How much exercise does your pet get daily

5+ hours 3-5 hours 1-3 hours Less than 1 hour

Any known commands?

Any additional comments on things you like?

Any additional comments on things you dislike?

Acknowledgement

I understand and acknowledge the following guidleines of surrender:
1. I am the undersigned and the owner or duly authorized agent for the owner of the animal(s) described above.
2. If K9 Hope Broker accepts the animal, the animal will be evaluated by the K9 Hope Broker staff to determine its suitability for adoption or placement with an approved foster home.
3. I understand that K9 Hope Broker makes no assurance that the animal(s) will be placed for adoption or rescue and that determining factors such as age, temperament, or medical conditions may necessitate the animal(s) being humanely euthanized.
4. understand that I am required by law to disclose if the animal(s) has/have bitten anyone in the last 10 days.
5. I understand that if I surrender an animal(s), I cannot adopt from K9 Hope Broker for two (2) years.

Full Name (Digital Signature)

Date

Rehome a pet
for a BETTER LIFE!

Pet Surrender Application (Digital)

Rehome a petfor a BETTER LIFE!

Pet Surrender Application (Digital)

Rehome a pet
for a BETTER LIFE!