Owner Surrender

Northstar Owner Surrender

There are times that necessitate the surrender of your pet. If you feel you are this point, complete the intake form here. Once we receive a completed intake we will review and assign a coordinator who will reach out within 24 hours We are a foster based rescue and as such are only able to take pets into foster as we have availability. We are a 100% volunteer group that is willing to work WITH you to safely place your pet in an appropriate forever home. Your pet needs to be fully vaccinated and altered prior to placement. We will work with you to accomplish this.

"*" indicates required fields

About your Dog

Please answer ALL questions below.

Today's Date*

Month

Day

Four digits

Dog's Name*

Intake #

Age*

Breed*

Gender*

Male

Female

Spayed / Neutered*

Yes

Microchipped?*

Yes

If yes, microchip #

Why are you surrendering this dog? (Please provide as much information as you can.)*

How long have you owned the dog?*

How many homes has the dog had?*

Where did you get the dog?*

Bite History

Has the dog scratched or bitten a person in the last ten (10) days?*

Yes

If yes, who was bitten?

Date of bite

Month

Day

Year

In what city?

Has the dog ever:*

Bitten

Scratched

Lunged or attacked

None of these

Did the bite break the skin?

Yes

Was Animal Control involved?

Yes

Please explain the circumstances:

Vet Information & Medical History

The dog's veterinarian:*

City & State*

Vet's Phone:*

Is the dog current on vaccinations?*

Yes

Please list any past or present injuries, treatments or other medical history:*

Please be specific.

Temperament

Check all of the following that describe the dog:*

Very active

Couch potato

Barks a lot

Quiet

Playful

Friendly

Fence Jumper

Shy

Likes to be touched

Affectionate

Fearful

Independent

Protective

Always at your side

Indoor dog

Outdoor dog

Nervous

House trained

Crate trained

Likes men

Likes women

Worked livestock

Used for hunting

Separation anxiety

Digger

Has the dog lived with children?*

Yes

If so, what ages?

Would you recommend your dog live with children in the future?*

Yes

Has the dog lived with cats?*

Yes

Would you recommend your dog live with cats in the future?*

Yes

Has the dog lived with dogs?*

Yes

Would you recommend your dog live with dogs in the future?*

Yes

What are the dog's favorite activities or objects?*

What does the dog dislike or fear?*

Where is the dog kept during the day?*

Does your dog travel well in the car?*

What type of food do you feed your dog?*

Is there anything else a future owner should know about this dog?*

Additional info

File uploads

You may upload images and documents here if you like.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 1 GB, Max. files: 10.

Agreement of Terms

Consent*

My signature below certifies that I am the owner of, or have the authority to surrender to Northstar Placment, the animal described above. I hereby relinquish all rights of ownership and any right to information on the disposition of said animal. I also authorize the release of any veterinary records regarding the animal. I certify that to the best of my knowledge I have disclosed all information about the animal concerning health, behavior, history and anything else that may affect the safe placement of the animal in a new home, and that all statements made above are true and correct.

I hereby acknowledge that I have been notified of and fully understand the following conditions of my relinquishment of this animal.

Northstar Placement shall have sole and exclusive legal right to make all outcome decisions and take all actions deemed appropriate, including return to owner, adoption, or euthanasia.

I have read the terms and agree.

Owner's Signature*

Date*

Month

Day

Four digits

Owner Information

Owner*

Please print

First Last

Phone:*

Email*

Address:*

Street Address Address Line 2 City State ZIP Code

Phone

This field is for validation purposes and should be left unchanged.

Northstar Owner Surrender

"*" indicates required fields

About your Dog

Please answer ALL questions below.

Today's Date*

Month

Day

Four digits

Dog's Name*

Intake #

Age*

Breed*

Gender*

Male

Female

Spayed / Neutered*

Yes

Microchipped?*

Yes

If yes, microchip #

Why are you surrendering this dog? (Please provide as much information as you can.)*

How long have you owned the dog?*

How many homes has the dog had?*

Where did you get the dog?*

Bite History

Has the dog scratched or bitten a person in the last ten (10) days?*

Yes

If yes, who was bitten?

Date of bite

Month

Day

Year

In what city?

Has the dog ever:*

Bitten

Scratched

Lunged or attacked

None of these

Did the bite break the skin?

Yes

Was Animal Control involved?

Yes

Please explain the circumstances:

Vet Information & Medical History

The dog's veterinarian:*

City & State*

Vet's Phone:*

Is the dog current on vaccinations?*

Yes

Please list any past or present injuries, treatments or other medical history:*

Please be specific.

Temperament

Check all of the following that describe the dog:*

Very active

Couch potato

Barks a lot

Quiet

Playful

Friendly

Fence Jumper

Shy

Likes to be touched

Affectionate

Fearful

Independent

Protective

Always at your side

Indoor dog

Outdoor dog

Nervous

House trained

Crate trained

Likes men

Likes women

Worked livestock

Used for hunting

Separation anxiety

Digger

Has the dog lived with children?*

Yes

If so, what ages?

Would you recommend your dog live with children in the future?*

Yes

Has the dog lived with cats?*

Yes

Would you recommend your dog live with cats in the future?*

Yes

Has the dog lived with dogs?*

Yes

Would you recommend your dog live with dogs in the future?*

Yes

What are the dog's favorite activities or objects?*

What does the dog dislike or fear?*

Where is the dog kept during the day?*

Does your dog travel well in the car?*

What type of food do you feed your dog?*

Is there anything else a future owner should know about this dog?*

Additional info

File uploads

You may upload images and documents here if you like.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 1 GB, Max. files: 10.

Agreement of Terms

Consent*

I have read the terms and agree.

Owner's Signature*

Date*

Month

Day

Four digits

Owner Information

Owner*

Please print

First Last

Phone:*

Email*

Address:*

Street Address Address Line 2 City State ZIP Code

Phone

This field is for validation purposes and should be left unchanged.

Heaven Can Wait Rescue • Northstar Dogs for Adoption

Heaven Can Wait Rescue • Northstar Dogs for Adoption

Northstar Owner Surrender

About your Dog

Bite History

Vet Information & Medical History

Temperament

Agreement of Terms

Owner Information

Northstar Owner Surrender

About your Dog

Bite History

Vet Information & Medical History

Temperament

Agreement of Terms

Owner Information