SMALL BREED RESCUE OF KENTUCKY
SURRENDER FOR ADOPTION FORM
A facilitator will contact you once you have contacted us via the "contact Us" form.. We will set up a time to meet with
you about your pet. Please print this form and fill it out for our records. Please make an extra copy for yourself.
Surrendering Owner(s)___________________________________________________________
Address_______________________________________________________________________
Date of Surrender______________________ Telephone_______________________________
Owner of Dog ( Yes or No)______________ If not owner, please explain
______________________________________________________________________________
______________________________________________________________________________
Reason for Surrendering _________________________________________________________
SBRKY Member Name__________________________________________________________
Member’s Address______________________________________________________________
Surrender Donation ( Yes or No)__________ Amount __________________ (Non-refundable)
It is understood that Small Breed Rescue of Kentucky does not buy or pay for dogs. This is a service to help place
yorkies in new homes when their present owners can no longer keep them. This services is free, however a donation
to help pay for expenses is appreciated.
Please respond to the following to the best of your ability- this information will help SBRKY in the placement of your
surrendered dog into their new home.
Yes No Yes No
Housebroken? Digs?
Crate Trained? Dog Aggressive?
Leash Trained? Jumps fence?
Barker? Obedience Trained?
Sleeps in House? Sleeps on bed or furniture?
Does Tricks? Gets along with Cats?
Gets along with other Animals? Chews?
Rides Well in Car? Gets along with Children?
Has your dog Ever Bitten Has your dog ever Attempted
another animal? To bite another animal?
Has your dog Ever Bitten Has your dog ever Attempted to
A person? Bite a person?
Type of Dog Food:______________________________________________________________
Type of Treats:_________________________________________________________________
Feeding Per Day: AM____ PM_____ or Both______
TERMS OF SURRENDER
I. Terms of Release
We, the surrendering owner(s), hereby agree to irrevocably surrender to the Surrender Facilitator the following so
described Dog:
Name____________________ Sex__________________ Age__________________________
DOB_____________________ Breed___________________ Coloring___________________
Spayed/Neutered_________________ Date____________________
Last Vaccinations:________________ Last HW Test: ________________________________
Last HW Preventative_____________ Name of HW Preventative Given__________________
Last Flea Preventative_____________ Name of Flea Preventative Given__________________
Name, Address & Phone Number of Vet’s Office where Vet Records could be obtained:
Note: Please phone your vet’s office and give permission for a SBRKY member to call them and get this information.
_____________________________________________________________________________________________
_______________________________________________________________
Microchip # (If applicable)________________________________________________________
II. Owner’s Representations and Warranties
We hereby represent and warrant to the Surrender Facilitator, successors and assignees, that we are the sole owner
(s) of the above described Dog, that we have unabridged authority to surrender this animal. We furthers assert that
we are registered as the sole owner(s) of this Dog with the AKC, or other pedigree registry, and require no other
individual or institution’s permission to affect a transfer of ownership of said pedigree registration papers. No other
individual or institution has any legal or equitable interest in this animal.
III. Owner(s) Document and Information Provision
We agree to provide the Surrender Facilitator with any documents and all other available information concerning this
Dog that may facilitate matching this dog with the proper adoptive home. These documents may include veterinary
records, vaccinations records, and pedigree registrations. We also agree to provide personal knowledge of the Dog’s
history, habits, and personality characteristics.
IV. Owner(s) Surrender of Rights
With the execution of this document, we cede all rights, title, privileges, and interests in the aforementioned Dog. It is
understood that this revocation extends to all future decisions concerning this dog made by the Surrender Facilitator
including medical and adoptive requirements. We further stipulate that the Surrender Facilitator has sole discretions in
determining whether the dog’s temperament, health, especially chronic, irreversible, life-threatening, and/or painful
aliments render the dog unsuitable for adoption, requiring unforeseen actions.
V. Release and Indemnity
We agree and understand that herewith we release and hold harmless the Surrender Facilitator form any and all
liability arising form the placement for adoption or any other necessary and appropriate action undertaken by the
Surrender Facilitator on behalf of the aforementioned Dog in accordance with and in reliance on the representations
made and the authorizations given under the terms of this document.
We agree to hold harmless the Surrender Facilitator from any damages suffered, expenses incurred, including legal
fees in defending or pursuing any legal action, whether for bodily injuries, death, property damage, breach of contract,
or otherwise, whether instituted by us or by any other individual(s) including the adoptive owners, arising out of or in
consequence of the placement of this Dog, in reliance on the authorizations, representations, and guarantees we
have made in this agreement.
This constitutes the entire agreement between Surrender Facilitator and us and no other terms or conditions or
implied.
THIS IS A LEGALLY BINDING DOCUMENT FOR THE SURRENDER OF THE AFOREMENTIONED DOG. PLEASE
READ THIS CONTRACT CAREFULLY AND COMPLETELY. BE CERTAIN YOU UNDERSTAND ALL TERMS BEFORE
SIGNING.
Surrendering Owner(s)________________________________ Date_______________________
________________________________ Date______________________
Surrender Facilitator _________________________________ Date_______________________
Print a copy and submit it to 334 Willow Oaks Drive, Nancy KY. 42544
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