Animal House Rescue
A Non-profit 501(c)(3) Organization Dedicated to Dog Rescue and Adoption
114 South Sporting Hill Road, Mechanicsburg, PA 17050
Phone: 717- 737-4300 / Fax: 717-737-7057 / Sharon@AnimalHouseRescuePA.org
www.AnimalHouseRescuePA.org / www.AnimalHouseRescuePA.petfinder.org
Like us on Facebook!! www.facebook.com/AnimalHouseRescuePA
SURRENDER APPLICATION
Please note that completion of this application is not a guarantee that Animal House Rescue will be able
to accept the dog(s) into our rescue. Surrenders are accepted based on a number of circumstances and
you will be contacted if your surrender is accepted.
Please complete all information below and send this document, along with photos to
Sharon@AnimalHouseRescuePA.org
Date:
OWNER NAME:
Address:
Phone #’s:
Email Address:
DOG NAME:
Breed:
Age/DOB:
Color:
Gender: (Male or Female)
Altered/Fixed:
Approximate Weight:
Scars/tattoos/microchip/injuries:
MEDICAL: Please provide any medical paperwork.
Veterinarian:
Is the dog current on vaccinations?
When was the dog to the vet last?
Has this dog been diagnosed with any medical conditions?
We are a partner of Animal House & Co., Inc., and receive funding for our Rescue through their profits.
Consider visiting Animal House & Co, Inc. for Dog Grooming – Doggie Daycare – Bed & Breakfast
Is the dog currently on any medications?
1. Reason for surrender:
2. How long has this dog lived with you?
3. Where did you get this dog from?
4. List the dog’s likes:
5. List the dog’s dislikes:
6. Is your dog sensitive to touch anywhere? (Ears, feet, tail, etc)
7. Is your dog sensitive about being held or picked-up?
8. Does your dog enjoy being bathed or groomed?
9. Dog’s training history?
10. Types of training tried? (Prong Collar, Electric Shock, Choke Chain, Treats, Clicker, Praise, Training
Classes, Halti, Gentle Leader, etc.)
11. What commands does your dog know:
12. Has this dog ever bitten anyone? If yes, please explain.
13. How would you describe your dog? (Lap Lover, Mellow, Social Butterfly, Loner, Curious,
Shy/Fearful, Active, Playful, Couch Potato)
14. Does your dog have any fears or anxieties? If yes, please explain:
15. How would you describe your household? (Active, Quiet, Average)
16. Does your dog have accidents in the house? If yes, how often.
17. Where does your dog spend most of its time? □ Inside □ Outside □ Inside/Outside
18. Do you have a fenced-in yard? If no, how do you potty your dog:
19. Does your dog climb/jump fences? If yes, please explain the circumstances.
20. How long is your dog left outside each day?
21. How long is your dog left alone inside your home each day?
22. Where is the dog kept when home alone?
23. Does your dog destroy things in the house when left alone?
24. Is this dog crate trained?
o
Do you still use a crate?
25. Where does this dog sleep at night?
26. Do you take your dog for leash walks?
o
If yes, how often.
o
How is your dog on a leash?
27. What type of daily exercise does your dog receive?
28. How do you correct this dog?
We are a partner of Animal House & Co., Inc., and receive funding for our Rescue through their profits.
Consider visiting Animal House & Co, Inc. for Dog Grooming – Doggie Daycare – Bed & Breakfast
29. What animals has this dog lived/interacted with? (Dogs, Cats, Other)
30. Does this dog get along with cats?
31. Has this dog ever injured/killed another animal? If yes, please explain the circumstances.
32. What is your dog’s reaction towards the other dogs? .(Friendly, Playful, Aloof, Aggressive, Easy
Going, Tollerant, Dominant, Submissive, Cautious, Fearful, Shy, Plays Rough, Rambunctious,
Protective, No Interaction)
33. Does this dog have any negative reaction to other dogs? If yes, please explain.
34. Has the dog ever lived with or interacted with children? If yes, list age range:
35. What is the dog’s attitude towards children?
(Friendly, Playful, Aloof, Aggressive, Easy Going, Tollerant, Dominant, Submissive, Cautious,
Fearful, Shy, Plays Rough, Rambunctious, Protective, No Interaction)
36. Describe this dog’s favorite game or toy:
37. Does this dog enjoy: Agility, Water, Hiking, Walks, Running, Ball, Frisbee, Toys, Tugging, Digging,
Being Home Alone, Car Rides, Quiet Time …
38. Fears/Dislikes: (People, Men, Women, Children, Dogs, Being Left Alone, Loud Noises, Riding in a
car, Everything, Groomer, Water, Nothing, Unknown)
39. How does this dog respond to its fears/dislikes? (Biting, Cowering, Hiding, Running Away, Shaking,
No Obvious Sign)
40. Describe your dog’s idea of a perfect day:
41. If you could change one thing about your dog, what would it be?
42. Is there anything else you would like the dog’s next owner to know?
43. I understand that a surrender fee of $100.00 (per dog) is required, made payable to Animal House
Rescue, at the time of surrender if we are able to take the dog.
44. Please review the copy of the surrender contract as listed here below and posted on our website.
For EACH dog, Please send photos of the dog when submitting your surrender application that
include a photo of the entire dog (head, body, tail) and a picture of just the dog’s face showing the
eyes.
By completing this application and submitting it to Animal House Rescue, you acknowledge that all
answers to all questions are, to the best of my knowledge, accurate & true, you acknowledge that you
have reviewed the surrender contract listed below and understand that you will be signing this document
if your dog(s) are accepted as surrenders to Animal House Rescue and that you will pay a surrender fee of
$100 per dog.
Name of person submitting application:
Date:
Once completed, please send this document, along with photos to Sharon@AnimalHouseRescuePA.org
We are a partner of Animal House & Co., Inc., and receive funding for our Rescue through their profits.
Consider visiting Animal House & Co, Inc. for Dog Grooming – Doggie Daycare – Bed & Breakfast
Please note that completion of this application is not a guarantee that Animal House Rescue will be able
to accept the dog(s) into our rescue. Surrenders are accepted based on a number of circumstances and
you will be contacted if your surrender is accepted. The following is a copy of the contents of our
surrender contract that you will be asked to sign should your dog(s) be accepted as surrenders to our
rescue.
This is a contract between Animal House Rescue (hereinafter called AHR) and the pet owner whose
signature appears below (hereinafter called “Owner”).
1. Owner agrees to give up all rights of possession and ownership of said dog and the Owner will not be
able to redeem said dog at any time.
2. Owner will not be allowed to know the dog’s whereabouts.
3. Owner's surrendering of said dog is in exchange for evaluation and placement by AHR.
4. Owner agrees that said dog is now the sole property of AHR.
5. Owner gives authorization to AHR to obtain veterinary records on said dog.
6. Owner specifically represents that s/he is the sole owner of the pet, free and clear of all liens and
encumbrances.
7. Owner specifically represents to AHR that the pet has not been exposed to rabies or distemper within
the past thirty days.
8. Owner specifically represents that said dog has never bitten any human, unless previously disclosed.
9. This Contract contains the entire agreement between the parties. All terms and conditions of this
contract shall be binding on the heirs, administrators, personal representatives and assigns of the
Owner & AHR.
10. By signing this contract and leaving his/her pet with AHR, Owner certifies to the accuracy of all
information given about said pet and that AHR will not be held liable or chargeable for any false
information or any misrepresentation that Owner may have submitted on this form.
11. A surrender fee of $100.00 (per dog) is required, made payable to Animal House Rescue, at the time
of surrender if we are able to take the dog.
We are a partner of Animal House & Co., Inc., and receive funding for our Rescue through their profits.
Consider visiting Animal House & Co, Inc. for Dog Grooming – Doggie Daycare – Bed & Breakfast