Dog: Owner/Guardian SURRENDER Contract - Humane Society of the Black Hills
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Humane Society of the Black Hills
1820 E. St. Patrick Street
Rapid City, SD
(605) 394-4170
(605) 355-3430 (fax)
Dog: Owner/Guardian SURRENDER Contract
Your Name:___________________________________ Your D.O.B. ____________
Phone ___________________________________ # of Animals Surrendering ________
Address __________________________ City/State/Zip _________________________
DOG’s Name _______________________________ Breed ______________________
Primary Color ______________________________ Pattern _____________________
Age _____________ Gender: Male/Female Neutered/Spayed? Y/ N
Animal ID (staff use only) _____________________________Microchip #_______________________________
PLEASE READ AND SIGN THE FOLLOWING:
• I, _______________________________________, do hereby relinquish all rights of ownership of the above
animal to become sole property of The Humane Society of the Black Hills on the __________ day of
____________________, 20_____.
• I understand that the HSBH does not guarantee placement of this animal or the length of time the animal will be
held for adoption and his or her final disposition, including adoption or euthanasia, because this is at the sole
discretion of the HSBH. Nor will HSBH release any information about such final disposition.
• I understand that the HSBH is under no obligation to return this animal to me during the period between its
surrender and its disposition.
• I understand that the HSBH has a policy that if I surrender an owned animal, I will not adopt another animal
from this facility for a period of six months.
• I affirm that I have not taken this animal from another person without consent. I am the legal owner.
• To the best of my knowledge, this animal HAS/HAS NOT bitten in the last 10 days
and IS/IS NOT sick.
The Humane Society of the Black Hills requires a surrender fee for all animals.
The decision of the length of stay and its final disposition, including euthanasia, will be the sole decision of The Humane
Society of the Black Hills. The Humane Society of the Black Hills is under NO obligation to return this animal to me during
the period of its surrender and final disposition.
NOTE: Owners are liable for all charges an animal has incurred through Humane Society of the Black Hills or
Animal Services and Enforcement services even after surrendering the animal. Surrendering an animal does
not negate previous or current fees for services.
Signature: ________________________________________________ Date: ____________
The animal legally now becomes the property of The Humane Society of the Black Hills.Dog’s Name_____________________________ Pet Point #________________________ How long has this dog lived with you? _________________________________________ Where did you obtain this dog? ______________________________________________ Please explain why you are relinquishing. ______________________________________ Dog Health: What kind of food does your dog eat? ________________________________________ Is your dog current on vaccinations? Y / N How does your dog behave at the vet? ________________________________________ Any medical concerns? _____________________________________________________ I, as legal owner of the animal, relinquish all rights to this animal and authorize The Humane Society of the Black Hills to request ALL medical records pertaining to the relinquished animal from my veterinarian:_________________________________________(name of veterinarian) Dog Behavior & Habits: In order to help your dog make the best possible match with a new home, please tell potential adopters of any habits or needs, good or bad that they should know about_____________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Is your dog primarily an indoor dog? Y / N If dog spends time outdoors, for how long? _______________________________________________ Is your dog kennel trained? Y/N If dog is kennel trained, how long is he left in kennel?_______________________________________ What is your dog’s favorite game/activity? _______________________________________________
I Enjoy: I’m Afraid Of: I’m Described As: My Noise Level: Previous Training:
☐ Agility ☐ Being Left Alone ☐ Lap Loving ☐ High ☐ None
☐ Digging ☐ Children ☐ Curious ☐ Moderate ☐ Minimal
☐ Car Rides ☐ Loud Streets ☐ Friendly ☐ Low ☐ Some
☐ Climbing ☐ Loud Noises ☐ Mellow ☐ Fully
☐ Dog Park ☐ Men ☐ Active My Energy Level: ☐ Extensive
☐ Fetch ☐ Riding in Cars ☐ Playful ☐ High
☐ Hiding ☐ Uniforms/Hats ☐ Loner ☐ Moderate I Lived:
☐ Quiet ☐ Water ☐ Social Butterfly ☐ Low ☐ Indoors
☐ Running ☐ Women ☐ Submissive ☐ Outdoors
☐ Toys ☐ ______________ ☐ Loner ☐ Both
☐ Walking Commands Known:_____________________________________________________
☐ Swimming Bad Habits:____________________________________________________________
Additional Comments:_____________________________________________________________________
_______________________________________________________________________________________
Lived with Dogs #________ Lived with Cats #________ Lived with Children #_______
Breeds_________________ Circle ages: Babies Under 5
______________________ 6-12 13 and up
☐ Aggressive Towards ☐ Aggressive Towards Babies, Toddlers, Kids, Teens
☐ Bites/Snaps ☐ Bites/Snaps ☐ Aggressive Towards
☐ Cautious/Submissive ☐ Cautious/Submissive ☐ Bites/Snaps
☐ Tolerates ☐ Tolerates ☐ Cautious/Submissive
☐ Playful/Rambunctious ☐ Playful/Rambunctious ☐ Tolerates
☐ Fearful ☐ Fearful ☐ Playful/Rambunctious
☐ Friendly ☐ Friendly ☐ Fearful
☐ Chases ☐ Chases ☐ Friendly
☐ Chases I
would recommend my dog live with (circle all that apply) :
Dogs Cats Children: Babies Under 5 Kids TeensAggression to People Does your dog show aggression to people? Y / N Who is the aggression directed towards and what is the response? ☐ Familiar Adults ☐ Unfamiliar Adults _____ Lunge _____ Growl _____ Bark _____ Bite _____ Chase ☐ Children Under 6 ☐ Children 6 – 12 _____ Lunge _____ Growl _____ Bark _____ Bite _____ Chase ☐ Men ☐ Women _____ Lunge _____ Growl _____ Bark _____ Bite _____ Chase Comments: _________________________________________________________________ ___________________________________________________________________________ Aggression to Animals Has your dog been aggressive to other animals? Y / N If yes, please answer the following questions: Type of animals the dog is aggressive towards and response: ☐ Familiar Dogs ☐ Unfamiliar Dogs _____ Lunge _____ Growl _____ Bark _____ Bite _____ Chase ☐ Familiar Cats ☐ Unfamiliar Cats _____ Lunge _____ Growl _____ Bark _____ Bite _____ Chase ☐ Other _____________________________________________________________________ _____ Lunge _____ Growl _____ Bark _____ Bite _____ Chase Comments: ______________________________________________________________________________ ______________________________________________________________________________
House Training Is your dog house trained? Y / N If not, please answer the following questions: In what circumstances does house soiling take place? ☐ Any time ☐ When person is home ☐ When person is not home ☐ In front of the person ☐ In another room ☐ Right after coming back inside How often does this happen? ☐ Only 1 time ☐ Daily Dog Escape Does your dog try to escape out of your home/fence? Y / N If yes, please answer the following questions: How does the dog escape? ☐ Darts out the door ☐ Jumps/Climbs 6 ft. fence ☐ Jumps/Climbs 4 ft. fence ☐ Chews through fence ☐ Opens doors or gates ☐ Digs under fence How often does this occur? ☐ A few times ☐ Almost every day ☐ Always trying to escape How hard does the animal try to escape? ☐ Puts a great deal of effort into it ☐ Only if given a good opportunity Dog Destruction Has your dog been destructive in your home? Y / N If yes, please describe when it started/how often if happens and the type of destruction: ________________________________________________________________________ ________________________________________________________________________ ______________________________________________________________________________
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