Request to Surrender My Pet

Midland County Pit Stop Pet Surrender Request

* Indicates required field

Name: First, Middle, and Last *

Birthdate *

Physical Address *

City *

State *

Zip Code *

Day Phone *

Cell Phone *

Email *

Reason for Surrender *

Please fill the portion out for any and all pets being surrendered to Midland County Pit Stop.

PET PROFILE

Pet's Name *

Gender *

Weight *

Breed *

Age *

Spayed/Neutered? *

Microchipped? *

If so, Microchip Number *

Housebroken? *

Yes No

Crate Trained? *

Yes No

Socialized Regularly? *

Yes No

Health Concerns *

Feeding Instructions/Food/Allergies *

Medications *

Favorite toy, game or treat *

Has your pet ever been aggressive or bitten anyone? *

Yes No

If yes, please explain *

Is your pet afraid of car rides? *

Yes No

Is your pet afraid of the Vet? *

Yes No

Does your pet do well with children? *

Yes No

Does your pet do well with dogs? *

Yes No

Does your pet do well with cats? *

Yes No

Does your pet walk respectfully at your side on a leash? *

Yes No

Has your pet ever been cared for outside of your home, by a sitter, kennel or dog walker? *

Yes No

If no, what sets him/her off? *

If so, please indicate name and contact number *

What commands does your pet know? *

Please indicate any behavioral issues. *

I, (TYPE NAME BELOW) release ownership of my dog(s)/ cat(s), listed above, to Midland County Pit Stop in Midland, Michigan. *

In surrendering my pet(s) to Midland County Pit Stop, I am absolved of all liability and financial responsibility resulting from my pet's health, behavior, or training. In surrendering my pet(s) to Midland county Pit Stop, I forfeit the right to make decisions regarding my pet(s) private adoption, health, behavior and or trains as of the date lists above. **** PLEASE INITIAL**** *

Date *

If my pet(s) is/are determined to be too dangerous to rehome or becomes ill or injured to a level that is deemed life threatening by the vet that Midland County Pit Stop works with, Midland County Pit Stop reserves the right to make all decisions pertaining to my pet(s) treatment and adoption process. **** PLEASE INITIAL**** *

Date *

I understand Midland County Pit Stop does not buy or pay for pets. The service we provide is to help place pets in new homes when their present owner can no longer care for or keep said animal. The service is free and a donation is appreciated to aid in the care of the pet until he/she is adopted. ****PLEASE INITIAL**** *

Date *

I hereby relinquish all rights to the above named pet(s) to Midland County Pit Stop. I hereby certify that I am the legal owner of the cat/dog. (licensing and vet documentation are required as proof of sole ownership or signature by a co-owner required). I hereby certify that this pet is not dangerous, vicious and has no bite record. I have not willfully concealed any information about the pet that might indicate such behaviors. I further understand and agree that I received no money or any other compensation as a result of this surrender, I hereby relinquish all claims to said pet and understand that this surrender is irrevocable and ownership of this pet is relinquished to Midland County Pit Stop. I understand that if I willingly lied or mislead any truths of said surrendered animal I could be held responsible for any legal ramifications. ****PLEASE INITIAL**** *

Date *

Owner Signature *

Date *

Owner's Printed Name *

Co-Owner's Signature *

Date *

Co-Owner's Printed Name *

Midland County Pit Stop Representative Signature *

Date *

Midland County Pit Stop Representative's Printed Name *

Submit

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Midland County Pit Stop Pet Surrender Request