First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Cell Phone

Birthdate: (Must be 18+ Years of age)*

What is the name for the animal you wish to surrender?*

Are you the current owner of the Animal you want to surrender?*
Choose one: Yes No

How long have you owned this animal?*

Did you originally adopt this animal from us? (Mending Spirits Animal Rescue)*
Choose one: Yes No Unknown

If yes, please list the date (MM/YY) of adoption and the name in which it had when in MSAR care.

Did you adopt this animal from a rescue or shelter that was not Mending Spirits Animal Rescue?*
Choose one: Yes No Unknown

If yes, please list the rescue or shelter name that you originally adopted this animal from?

Has your animal ever bitten or attempted to bite a person or animal? *

What type of animal are you surrendering? *DOGS ONLY- Video footage of your dog interacting with other dogs is required prior to admission into the program. (Young puppies are exempt from this requirement)

List any known breeds for your animal: *

Estimated or known weight of the animal: *

Do you know the animals date of birth? (Please list)*

Gender:*
Choose one: Male Female Unknown

Please Check ALL that apply to the pet you are surrendering:

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

Up To Date? Most current Vet records required

PLEASE NOTE:

• Animals being surrendered (species & age-appropriate) MUST have a current rabies vaccination and submit the animal's rabies certificate before we can transfer into custody. Exceptions will ONLY be granted for specific circumstances.

• Animals residing outside of Minnesota MUST have a valid health certificate before we can transfer into custody and submit the animal's certificate before we can transfer into custody.

Current Vet Name: *

Vet's Phone Number: (Required field: If no vet, please enter NA)*

Vet's Address:

Please Describe your animal in detail? Personality/temperament, history, training?*

Please Describe Any Current or Past Medical Issues For This Animal in Detail:*

Why do you wish to surrender your pet at this time?*

Comments:

How did you hear about us?

By signing below I hereby certify that I am the rightful owner/ keeper/ caretaker/ custodian of the animal(s) who is/are the subject of this animal surrender form, hereinafter referred to as “the animal”. I hereby surrender any and all property rights to the animal and agree this is fully complete and finalized at the time the animal(s) is physically transferred into the care of a Mending Spirits Animal Rescue volunteer, representative or partnering veterinary clinic. I certify that no other person has a right of property to the animal(s). I understand that by surrendering my property rights to the animal(s), the animal(s) may be transferred into the custody of Mending Spirits Animal Rescue. I also hereby certify that the animal(s) has not bitten or scratched a human or another animal within the last 10 days, all bite history is disclosed in full that has been inflicted upon any animal or person, and that all history including medical or behavioral issues have been accurately presented and in full. I understand that once I relinquish the animal to Mending Spirits Animal Rescue, the animal(s) will NOT be available to be returned back to you or anyone other than an appointed Mending Spirits Animal Rescue representative or partnering veterinary clinic. I further certify that I have read and understand the terms of this animal surrender form. I Certify That the Above Information is True and Accurate: (enter name for signature)*