Finding A Local Shelter – If your only choice is giving up your pet to a shelter, here are some local resources that may be able to offer assistance.

• No Kill Networks – Consult nokillnetwork.org, or CARE for a list of no-kill shelters in your area.

• Adopt-a-Pet Self Rehome Option & Resources — Rehoming your pet should be easy and stress-free both for you and your pet. Experts at Adopt-a-Pet.com have created a simple, reliable, free program to help you place your pet from your loving home directly to another. Visit rehome.adoptapet.com

• Other Resources, including other Local Shelters — You can find other local rescues, along with animal control facilities and some breed/species specific rescues on our WCHS Contact Resources document.

Surrender Form

Please submit this application along with your pets medical records.

Once your application is submitted, management will contact you once intake space becomes available.

You will be required to schedule a meeting with management to review your pet’s medical history and evaluate their behavior. If approved, a surrender fee will be taken upon intake.

Owners Personal Information

Name *

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email *

Email

Confirm Email

Driver's License # *

Pet Information

Pet Name *

Species *

• Cat
• Dog

Gender *

• Female
• Male

Age *

Breed and Color

Primary Breed *

Primary Color *

Secondary Breed

Secondary Color

Has your pet ever bitten anyone? *

• Yes
• No

If yes, please describe:

Is your pet friendly with cats? Please describe. *

Is your pet friendly with dogs? Please describe. *

Is your pet friendly with strangers? Please describe. *

Where did you get your pet from? *

Friend, Shelter, Pet Store, etc.

Why are you looking to surrender your pet? Please be honest. *

Vet Information

REMINDER: A complete set of vet records is required to be submitted with this form.

Name of your Veterinary Clinic *

Address of Veterinary Clinic

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone Number of Veterinary Clinic *

Fax Number of Veterinary Clinic

Is your pet fixed? *

• Yes
• No

Is your pet current on vaccinations? *

• Yes
• No

Is your pet current on testing and/or preventions? *

• Yes
• No

Is your pet currently taking any prescription medications? *

• Yes
• No

If so, please provide the medication name along with a diagnosis of why the pet is taking the medication.

Does your pet have any pre-exisiting medical conditions? *

• Yes
• No

If so, please describe.

Please attach your pet's latest veterinary records.

Click or drag files to this area to upload. You can upload up to 20 files.

By checking below, *

• I am confirming that I have truthfully provided all of the information requested.
• I have read and confirm that I understand the Surrender Fee Information.

Submit