Safe Haven Surrender Contract
Please answer all questions truthfully and completely. This will help us
find the best home for your pet. The answers will not count against you
or the animal but help prevent an animal from being misplaced a second
time.
Email completed form to safehaven at epix.net or mail to:
Safe Haven, PO Box 225, Long Pond, PA 18334
Pet Name:
Age/Birthdate:
Breed:
Color/Markings:
Have you had this dog/cat since it was a puppy/kitten? _________ If no
where did you get it? _________________________ At what age: __________
Is the animal good with dogs? _________________ cats? _________________
kids? __________ what age group(s) ___________________________________
Spayed/Neutered: ________ Date: ________ Vet: ______________________
Shots/Dates: _________________________________________________________
Preventatives Used: ______________________________ Dates: ____________
Checked for heart worm or lyme disease? ________ If yes, when? _______
Checked for feline leukemia ? ___________ If yes when? ________________
Medications or medical conditions: ____________________________________
_______________________________________________________________________
Is the dog obedience trained? _____ Knows commands? ________________
House trained/litter box trained? _____
What kind of food do you use? ____________________ Treats? ___________
Are there any special dietary needs? ___________________________________
Is pet crate trained? _____ How many hours a day is pet left unattended?
______________________ Where is it kept? ______________________________
Is your home: noisy ______ active ______ quiet ______ average ______
Cats: Is cat declawed? _____ Does cat go outdoors? _____ Does the cat
claw furniture? _____ Bite? _____ Is the cat social and likes to be held or
a loner that comes for attention on his/her terms? _____________________
Does it allow you to brush him/her? _____ Afraid of anything? _________
If yes, what? ______________________________ Personality traits _________
________________________________________________________________________
Dogs: Does your pet chew? _____ Jump up? _____ Barks/howl? ______
Nip/Bite? _____ If yes under what circumstances? _____________________
________________________________________________________________________
Possessive of toys? ________ Bones? ________ Does it chase cars or other
animals? ________________________ Dig? _____ Ride in car? ____________
Like swimming/water? __________ Does dog allow you to brush it? ____
Wash it? ______ Clip nails? _____ Is dog frightened by anything? ______
If yes, what? __________________________________________________________
Personality traits ______________________________________________________
What type of home would best suit your pet? ___________________________
________________________________________________________________________
The reason for relinquishing this pet: __________________________________
________________________________________________________________________
I state that at no time did this pet exhibit aggression or viciousness
toward a human being or another animal other than what has been
disclosed to Safe Haven. ________ (Initial)
I hereby relinquish all claims and ownership of said pet to Safe Haven
and/or a representative. After I have signed this agreement I cannot
reclaim this pet.
I agree to give Safe Haven all paperwork and medical records and any
other relevant materials pertaining to this pet.
I have disclosed all medical, physical or hereditary problems that are
known to me at the time of relinquishment.
I verify that all statements are true and accurate according to my
knowledge.
Signature: ____________________________________________________________
Address: ______________________________________________________________
Phone: _______________________________ Date: _________________________
Email address: ________________________________________________________
Safe Haven volunteer: _________________________________________________
If your animal exhibits aggression of any form towards humans or other
animals the animal will be returned to you and we will refund any
donation made. We cannot take aggressive pets into our rescue. If this is
a recurring problem, the option of euthanasia is to be handled by you
and not Safe Haven.