Release/Surrender Form

Description of Siberian Husky, hereinafter referred to as "dog":

Registered Name (if available): AKC Number (if available):
Call Name: Sex: Age: Eye Color: Coat Color:

Health and History Information:

Breeder's Name (if Known):
Breeder's Address:
Vet's Name and Address:
Date of Current Shots: Has the dog ever been bred?
Heartworm? (has dog been tested?): On preventative?:
Housebroken?: Obedience trained?:
Prefers men or women?: Good with children?:
List Bad Habits:

 

If the dog has bitten a human being or animal, give particulars:

 

Reason(s) for surrendering this dog:

 

I/we hereby state that I/we are the sole owner(s) of the above-described dog and that there are no other parties that may have a legal interest in this dog.  I/we hereby surrender all of my/our interests and ownership rights in such dog to the Rescue Program and hereby relinquish all claims to such dog.  I/we understand that such surrender and release of my/our ownership rights in this dog is irrevocable.  I/we state and affirm that to the best of my/our knowledge, the said dog has not bitten any human being or animal unless full disclosure is made above.  I/we understand and agree that if I/we have not made full disclosure about any known bites, I/we agree to hold the Rescue Program harmless and indemnify the Rescue Program for any damages resulting from the dog's undisclosed propensity to bite.  I/we understand and agree that I/we am/are surrendering this dog to the Rescue Program of my/our own free will and that such surrender and/or release does not constitute a sale.  I/we further understand and agree that I/we will receive no money or other compensation as a result of surrendering this dog but that I/we have received a benefit from this surrender in that I/we can no longer care for this dog.

Such release is executed this ____________ day of _________________, 20__
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Signature of Owner
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Signature of Co-owner
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Address
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Address
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Telephone
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Telephone
Release/Surrender Donation_________________________