Pet Surrender Application Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Pet's Name* Name Species*DogCatBirdSmall AnimalOtherIf Other, please specify:Breed*Color*GenderMaleFemaleIs this pet spayed/neutered?*YesNoAge*Please note, we will also age your pet on intake.Weight*If this pet is a cat, is it declawed?YesNoIs this pet microchipped?*UnknownNoYesMicrochip NumberWhy are you looking to surrender this pet?*Have you made alternate attempts to place this pet? If so, where and why was it unsuccessful?*How long have you had this pet?*Where did you get this pet? Please list name of organization, rescue, or business.*Have you attempted to return the pet to that source?We are dedicated to helping pets and people stay together. If HSP could provide you with resources to keep your pet, which would you benefit from?* Free Pet Food Free/Low Cost Behavior Advice or Training Free/Low Cost Veterinary Care Temporary Housing for My Pet Benefits for Veterans Benefits for Seniors Free/Low Cost Spay/Neuter Advice on Moving with Pets Advice on Pets with Newborns/Kids General Pet Ownership Advice Other I am not interested in getting help to keep my pet If Other, please specify:The shelter is very stressful, especially for pets with medical and behavioral needs. Many pets benefit from remaining in a home environment while looking for a new home. If we provided you with everything you will need (food, supplies, vaccinations, surgery, etc.), would you be willing to foster your pet until it is adopted?*NoYesUnsureHow does this pet react to being brushed, bathed or groomed?*How does this pet react to having its nails trimmed?*Is there anywhere this pet does NOT like being touched? If so, where?*How does this pet behave with other pets? Please describe.*Does your dog have to be muzzled at the vet?UnknownNoYesFor dogs, does your dog have to be muzzled in public?UnknownNoYesHow would you describe your pet's personality?* Friendly Social Butterfly Timid Affectionate Anxious Aggressive Aloof Playful Stubborn Rambunctious Couch Potato Choose all that apply.What animals does your pet live with?* None/Not Applicable Female Dog(s) Male Dog(s) Female Cat(s) Male Cat(s) Male Rabbit(s) Female Rabbit(s) Male Bird(s) Female Bird(s) Small Animals (guinea pigs, hamsters, etc.) Other Check all that apply.Are there certain animal(s) your pet does not get along with?* None/Not Applicable Female Dog(s) Male Dog(s) Female Cat(s) Male Cat(s) Male Rabbit(s) Female Rabbit(s) Male Bird(s) Female Bird(s) Small Animals (guinea pigs, hamsters, etc.) Other Check all that apply.If you selected any animals that your pet does not get along with, please describe.(If your pet is afraid, aggressive, will chase, has bitten, etc.)Would you recommend a home with other animals?* Dogs Cats Bird Small Animals I would not recommend a home with other animals Other Check all that apply.If you selected "I would not recommend a home with other animals" or "Other," please describe.How is your pet with strangers?How is your pet with children?*FriendlyScaredAggressiveUnknownPlease describe.Please check who lives with this pet.* Adult men Adult women Children ages 0-2 Children ages 3-5 Children ages 6-9 Children ages 10-15 Young adults ages 16-21 Seniors (65+) Check all that apply.Is your pet social with visitors?*YesNoUnknownPlease describe.Is your pet housebroken and/or use the litter box?*HousebrokenNot housebrokenStill in trainingUses the litterboxDoes not use the litterboxOtherIf Other, please specify:Please describe your pet's housebreaking or litterbox routine.*(i.e. how often do you let your dog outside, how often do you clean the litterbox, etc.)Does this pet have any bad habits?*(raids the trash, scratches furniture, not housebroken, etc.)Does this pet live indoors, outdoors or both?*Indoors onlyOutdoor onlyIndoor/outdoor (contained)Indoor/outdoor (not contained)Is this dog crate trained?*YesNoWorking on it!UnknownHow long is your pet left home alone?*Please note time alone in hours per day.How is your pet housed when left alone (loose, crated, etc.)? How does your pet behave when left alone?Please check any commands your pet may know.* Sit Down Stay Shake/Paw Come Heel Speak Other If Other, please specify:Describe your pet's training history.*What veterinary hospital/veterinarian cares for your pet? If applicable, please list their phone number and location.Our Pet Resource Team may contact your veterinarian to review the pet's medical records.Can you provide medical records for this pet?*NoYesRecords can be brought with you or emailed to [email protected]Does your pet have any medical conditions that our staff should know about?*UnknownYesNoPlease describe.If this pet on any medication(s)?*UnknownNoYesPlease list any medications your pet is on, including flea/heartworm prevention.Please check all tests your pet has had within the past year.* Heartworm Test (Dogs) Feline Leukemia Test (Cats) Feline Immunodeficiency Virus Test (Cats) None Did you pet test positive for any of these tests? Which ones?*Is your pet current on all vaccinations?*N/AUnknownNoYesIs your pet on a prescription food?*UnknownNoYesWhat brand/type of food?Has this pet ever been aggressive?UnknownNoYesIf Yes, please describe in detail.Our Behavior Department may be able to work with your pet's aggression.Has this pet ever bitten anyone?*UnknownNoYesIf yes, how long ago did the bite occur?If yes, please describe the circumstances.This does not mean we will not accept your pet.Have your previously submitted an application for this pet?*UnknownNoYesBy checking this box, I certify that all information in this application is true to the best of my knowledge. I understand that HSP is a managed admissions facility and may not be able to accept my pet.* I understand