23 Inis Sioda, Tullyvarraga, Shannon, Co. Clare
Surrender of an Animal
Date: ______________
Phone: ____________________
Name: ______________________
Mobile: ______________________
Address: ______________________
______________________
______________________
Email: ________________________
Pet’s Name: _______________________
Breed: ________________________
Male / Female
Neutered / Spayed
Vaccinated Y / N Last Vaccine _____________
Age ___________
Colour _______________
Pedigree Y / N
Microchip ____________
Is your pet housetrained
Yes No Don’t Know Not allowed in the house
Is your pet good with children
Yes No Don’t Know
Is you pet used to other animals Yes No Don’t Know
Has your pet ever bitten or show aggression to people Yes No Don’t Know
Any Comments: (Medical conditions, feeding, etc)
Your Veterinary Surgeon’s Name: ____________________________________
I agree to surrender my pet to Second Chance Animal Rescue Ltd (S.C.A.R)
This pet is not a stray that I have found. The pet is legally mine.
All pedigree papers will be surrendered with my pet
The details I have given for this pet are true and correct
I understand that by signing this agreement that I am surrendering all rights to my pet and have no
rights to ask for my pet back in the future
I understand that S.C.A.R will not divulge details of new owners of my pet to me after rehoming
I have read the terms and conditions set out above and agree to abide by them
Signature: _________________________ Print name: ______________________ Date: _________
Witnessed: ____________________________ Print name: ________________
Donation received: €______________
God grant us the serenity to accept the
things we cannot change
Courage to change the things we can
And the wisdom to know the difference