Name
*
First Name
Last Name
Phone Number
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
When did you purchase this animal(s)?
*
MM
DD
YYYY
How long have you owned this animal(s)?
*
Is there a specific timeframe or deadline for this surrender?
*
Ex. moving, eviction, behavior
Are you on any other shelter or SPCA's waitlists at the moment? If so, please list them.
*
What species(s) are you wanting to surrender?
*
Number of animals you want to surrender:
*
If you have more than one animal being surrendered, would you classify them as bonded?
Bonded: the animals must never be separated and be adopted together. If separated, they would become distressed and depressed.
What is the breed, color, and weight of the animal you are wanting to surrender?
*
If you have multiple animals you want to surrender, please add answers to each.
Does your animal have any distinguishable markings or physical attributes?
*
If you have multiple animals you want to surrender, please add answers to each.
What is the gender of the animal you are wanting to surrender?
*
If you have multiple animals you want to surrender, please add answers to each.
What is the age of the animal you are wanting to surrender?
*
If you have multiple animals you want to surrender, please add answers to each.
Does the animal(s) have any symptoms of sickness?
*
Ex. sneezing, coughing, nose/eye discharge, wheezing, laboured breathing, vomiting, diarrhea
Does the animal(s) have any physical injuries, parasites, or deformities? If yes, please add detailed descriptions.
*
Ex. broken limbs, bite wounds, facial scarring/wounds, ticks, fleas
Does the animal(s) have any diagnosed medical conditions from their veterinarian?
*
What is your veterinarian's name, location, and phone number?
*
Is the animal spayed or neutered? If yes, what year was it done?
*
If you have multiple animals you want to surrender, please add answers to each.
When was the animal(s) last checkup at a veterinary clinic? Did they receive their annual vaccinations and parasite control?
*
If you have multiple animals you want to surrender, please add answers to each.
Does your animal have any enviromental or food related allergies we should be aware of?
*
If you have multiple animals you want to surrender, please add answers to each.
I agree to the following:
*
I understand that any information given will be held confidential.
By checking below, I certify that the information I have provided is true and that any misrepresentation of facts may result in losing the option to surrender. I understand that the Carleton County Animal Shelter has the right to deny my request to surrender an animal, and I authorize the investigation of all statements in this application.
Date of agreement
*
MM
DD
YYYY
Select from the following what we can help with during the wait.
Is there any other information not asked for that you feel is important for the CCAS staff to know during the triage process?
