Your Name:*
Street Address:*
City:*
State:*
Zip Code:*
Telephone Number:*
Alternate Phone Number:
E-mail:*
Dog Name:*
Dog Age:*
Date of Birth:*
Gender:
Weight:*
Photo of Dog:
Breed:*
Reason for Surrender:*
Any Health Issues?:*
Care currently give for health issues:
Date of Last Vet Visit:*
Vet Name:*
Vet Number:*
Vet Fax Number:*
May we contact your vet?:*
Up to date on shots?:*
Rabies Vaccination:
Rabies Date Done:
Parvo/Distemper:*
Parvo/Distemper Date Done:
Bordetella Vaccination:*
Bordetella Date Done:
Heartworm Test Done:*
Heartworm Date Done:
Heartworm Prevention Used:*
Fecal Test Done:*
Spayed/Neutered:*
Where did you get the dog?:*
If you received your dog from a rescue have you contacted that rescue?:*
Has the dog received any professional training?:*
Gets along with children:*
Gets along with other dogs:*
Gets along with cats:*
Has dog ever bitten:*
Please explain bite situation:*
Is dog house trained:*
Please explain why dog is not house trained:
RWC is dependent on donations to give the needed care to our rescues. Are you willing to make a donation to help with these costs?:*
If so, how much?:
How did you hear about RWC?:*
Have you contacted other groups?:*
If yes, please explain:
May we refer your request to another reputable group if we have no one to help you?:*

REPRESENTATIONS AND WARRANTIES - We hereby represent and warrant to Rescue Warriors., their agents, successors and assigns that the undersigned are the sole owner(s) of the above described dog. That I/We have full power and authority to surrender this animal for adoption, that I/we are the only person(s)who are listed as registered owner(s) of this animal. No other person(s) have any legal or equitable ownership interest in this animal.

PERTINENT INFORMATION - We agree to provide Rescue Warriors Corp. with any documents and all other available information concerning this dog which might assist in matching this dog with the proper prospective adoptive home, including health and shot records, pedigree, name and address of breeder or other person from whom the dog was acquired, and information concerning this dog’s history.

CONSENT FOR CONTACT - We understand that Rescue Warriors Corp. may contact the breeder or previous owner of the dog to provide additional background information, or otherwise assist in locating a suitable adoptive home and hereby give our consent to these efforts and agree, in good faith, to cooperate fully with these efforts.

SURRENDER OF RIGHTS - By Executing this document, we understand that we are giving up forever all right, title and interest to the above mentioned dog and we further understand that all future decisions regarding placement of this animal will be made solely by Rescue Warriors Corp. We also understand if this dog is later found to have such unpredictable temperament as to be unsuitable for any placement, or if the animals quality of life is substantially impaired, in the opinion of a competent veterinarian, by a chronic, irreversible, painful condition, Rescue Warriors Corp will have the sole right and discretion to utilize euthanasia.

I/we, the undersigned, hereby specifically and forever release, and hold Rescue Warriors Corp. harmless, from any and all liability arising from the placement for adoption by Rescue Warriors Corp. the above mentioned dog, ot for any other actions taken by Rescue Warriors Corp. in accordance with, and reliance on the representations we have made, and the authorization we have provided under the terms of this document. We agree to indemnify and hold harmless Rescue Warriors Corp. for any damages suffered and expenses incurred in defending any legal action, weather for bodily injuries, property damage, breach of contract, or otherwise whether instituted by us or by any other person(s) arising from the placement of the dog.

This is a legally binding and irrevocable surrender of your dog for placement to an adoptive home. Please read carefully and completely before submitting.