Dog Surrender Application This form will go to our Dog Director who will review it, determine if we can accept the dog, and contact you for further details. We aren’t able to take dogs that are aggressive or have a prior bite history. By typing your full name below, you signify that you are trying to surrender a dog to the Winona Area Humane Society. You understand that if WAHS can take the animal, you will be giving up all rights of ownership of this animal. You also understand that the Winona Area Humane Society will make every attempt to place the animal in a loving home. Should the animal be transferred into WAHS' care, you agree to pay a surrender fee of $100 for an intact animal or $50 for a spayed/neutered animal. * Today's Date * MM DD YYYY Your Phone Number * (###) ### #### Is this phone number a cell or landline? Cell phone Landline Your Email Address * Make sure the email address you enter is one you check frequently. Preferred method(s) of contact regarding your application: Email Text Call Your Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Animal's Name * Animal's Age * Animal's Breed * Reason for surrendering this animal * Please provide a description of the dog * How did you acquire this dog? * How long have you had this dog? * Has this dog ever bitten anyone? * Yes No If this dog has ever bitten someone, please describe the incident below. Please check any items that apply to this dog: Jumps fences Tears carpet Tears furniture Dumps trash Chases cars/bikes Walks well on a leash Rides well in cars Digs holes outside Digs/chews Likes cats Likes other dogs Should this dog be placed in a home without any of the following? Check all that apply. Other dogs Cats Other types of animals Children Where is this dog used to being kept? Check all that apply. Crate Free roaming House Yard Chained Is this dog crate-trained? * Yes No Where is the dog usually fed? How many times per day is it fed? * What brand/type of food is this dog currently eating? How much? * Is this dog sensitive to being touched? * Yes No Unsure If this dog is sensitive to being touched, please explain: MEDICAL HISTORY Is your animal: * A spayed female An intact female A neutered male An intact male Are medical/veterinary records available? * Yes No Name(s) and contact information of any veterinary clinics used: Date of last rabies vaccination * Rabies tag number Is there anything else you'd like to tell us about this pet? The more we know about how the dog acts in a home setting, the better chances we'll have of matching it to a suitable adopter. We appreciate any and all details that are shared! Thank you for submitting this application! If we’re able to accept the animal, one of our staff members will get in touch with you to discuss next steps.
