First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Cell Phone

Name of the animal being surrendered: *

What type of pet?*
Choose one: Dog Cat Rabbit Hamster Other rodent Farm animal (please specify)

What is the breed of the animal you are surrendering? (This helps us determine what kind of foster home is available.) *

**PICTURES ARE REQUIRED** before surrender can be looked at, please email us pictures of animal to surrender@pjsrescue.com to help us with placement of your pet and also please include a description of the animal, i.e. color and markings. This is necessary as we get many requests. *

Age*

Sex

What is the approximate weight of this pet?*

Is this pet spayed/neutered?

Do you own this pet or is this a found pet?

How long have you had this pet? *

If this is a found pet, what is the approximate address you found the pet and what (if any) places has this pet been networked?

Where did you obtain this pet?

If you obtained this pet from another shelter/rescue, which one and have you contacted them for a surrender to their care?

Please explain the reason for surrendering this pet. *

Is this pet housebroken or litter trained?

Is this pet kennel trained (if applicable)?

Which of these is this pet friendly with? (please check all that apply)

Has this pet been neglected abused, or lived in a home with another person/pet being neglected or abused?

Has this pet ever attacked or gotten into a fight with another pet?

If you answered yes, please explain the circumstances surrounding this event with as much detail as possible.

Has this pet ever bitten anyone or shown signs of aggression?

Has this pet ever been deemed potentially dangerous, dangerous or been involved in a police report?

Do you consider this pet to be protective?

Has this pet completed any obedience training?

What commands does this pet know? (Please select all that apply)

Can this pet jump or climb fences? If so, what height at maximum?

Does this pet require a special diet?

Please explain any good or bad behavior, traits or commands you feel is important for us to be knowledgable of. *

With the information you entered above, please create a bio on your pet so we can use this for our online request for fosters and or adopters. (ex. crate or potty trained? good with kids, other dogs, cats? loves to play with toys or play fetch. What basic commands do they know?) Thank you! *

Does this pet currently have a primary vet?

Who is the veterinarian and their number or clinic name?*

Are your vaccines updated? We require a current rabies and current distemper vaccine in order to surrender. Please contact your vet and have them email the certificates to surrender@pjsrescue.com OR attach the certificates to the email when you send pictures.

When was the last distemper vaccine (otherwise also known as DHPP, DAPP or similar combination)?*

When was your pets last rabies vaccination and is a 1 or 3 year vaccine? *

When was this pets last heartworm test? Was this positive or negative? *

Has this pet previously been treated for a positive heartworm test?

When was the pets last Bordetella vaccination?*

Does the pet have any of the following? (Please select all that apply)

Is there any other health or behavioral problems you wish to make us aware of? *

Is there a repairable barrier preventing you from keeping your pet? (Ex. unable to afford vet care, needing vaccinations, cannot afford pet deposit, leaving domestic vioelnce- we will provide you any resources we can to keep pets and their family together and this information will not be disclosed publicly without your consent).*

Do you understand that answering yes to any of these questions is not automatic disqualification for your pet?

Do you understand that it is critical to answer these questions with full honesty and transparency to prevent dangerous situations for both your pet and our volunteers?

Do you understand we are an exclusively foster based rescue and submission of this form is not a guarantee your pet will be offered placement?

If we are unable to locate a foster placement for your pet, would you consider surrendering to rescue under the understanding you will fostering the pet while in our care?

Do you understand that the rescue may request a $100 surrender donation? The surrendering fee is determined at the time of intake. If the rescue does not receive documentation that the animal being surrendered is up-to-date on vaccines and is spayed/neutered this fee may be charged.

I have read and fully understand the intake request form, as well as agree I have answered all questions with complete honesty and transparency. I agree that if my pet is accepted into rescue, I will be surrendering all rights for medical and placement decisions to the rescue. Enter your name and date. *