First Name*

Last Name*

Email*

Address:*

City:*

State:*

Zip Code:*

Home Phone:

Cell Phone:

Work Phone:

Name of pet:*

Pet type:*
Choose one: Cat Dog

Sex of pet:*

Age of pet:*

Approximate weight (lbs):*

Breed(s) of your pet:*

Is your pet a mixed breed?*
Choose one: Yes No

Describe the physical qualities (color, coat length, etc.) of this pet:*

How was this pet acquired?*

Why are you surrendering this pet?*

Was this pet originally adopted from Paws and Prayers?*
Choose one: Yes No Unknown

If yes, when was it adopted and what was its original name?

Is this pet spayed/neutered?*
Choose one: Yes No Unknown

Is this pet up to date on vaccinations?*
Choose one: Yes, all Most or some are up to date No, not up to date I'm not sure

Is pet kept on flea/tick/heartworm prevention?*

If yes, brand:

Name and phone number of last-seen veterinarian: *

Date and reason of last veterinary visit:*

Is pet microchipped? *
Choose one: Yes No Unknown

Does this pet have any known medical concerns (including dietary needs)?*

If yes, describe:

Is this pet friendly with...? (check all that apply. Hold down shift key to select multiple responses)
Choose all that apply: Dogs - small Dogs - big Cats Children under 5 years old Children over 5 years old Men Women Strangers

Is this pet aggressive with...? (check all that apply. Hold down shift key to select multiple responses)
Choose all that apply: Dogs - small Dogs - big Cats Children under 5 years old Children over 5 years old Men Women Strangers

Select any of the following descriptions that apply to the pet: (check all that apply. Hold down shift key to select multiple responses)
Choose all that apply: Housebroken/Litter-trained Crate trained Declawed Allowed on Furniture Spends Most Time Indoors Spends Most Time Outdoors Active Shy Dominant Independent Social Friendly Aggressive Submissive Affectionate Playful Has Completed Training Cuddly Guarding Runs Away

Has this pet ever bitten or otherwise harmed anyone? *

If yes, explain:

Has your dog been approved to attend doggie day care (dogs only)?*
Choose one: Yes No

If yes, where?

Are you willing and able to foster your own pet through the re-homing process (a Paws and Prayers representative is appointed to oversee the adoption process)?*
Choose one: Yes, as long as it takes Yes, for a little while No, I am looking for immediate placement

Additional comments or information you'd like us to know:

BY SUBMITTING THIS APPLICATION, you agree to the following:

I understand that I will be asked for my pet's medical records (those that are available); that Paws and Prayers will put an adoption fee on my pet to assure a good home and to cover any cost associated with accepting it into the program; that submission of this application is not a guarantee that Paws and Prayers will take my pet; and that I have read and reviewed the surrender policies.