Northern Lights Regional Humane Society
Box 481, 9702 – 97 Street
High Level, Alberta T0H 1Z0
Email: [email protected]
ANIMAL SURRENDER AGREEMENT
The Northern Lights Regional Humane Society (NLRHS) desires to be a service source where potential pet adopters can be
matched with animals in need of new homes. We recognize that unfortunate circumstances can develop in responsible pet
owners’ lives that cause them to consider parting with a beloved pet. However, surrenders are only taken if there is room
at the Shelter and only if the animal is determined to be an adoptable animal by an appointed Northern Lights
Regional Humane Society member/staff. Please note that NLRHS requires a non-refundable surrender fee of $50 (per
Dog) or $30 (per Cat). This fee is used to help defray expenses (veterinary care, food, shelter, etc.) related to animal care.
In an effort to make this parting (and subsequent search for a new home) less traumatic, we ask that you complete the
Animal Surrender Questionnaire on the reverse side of this document to aid in the search. It will also be very helpful if you
provide us with your pet’s veterinary records, and any toys or favorite blanket when you surrender your pet, to help him or
her acclimate to its new surroundings.
Pet Owner’s Information:
Moving to New Home
Unable to Care for Pet
Incompatibility Issues
No Longer Wanted
Name: __________________________________________________
Address: ________________________________________________
City/Prov: _____________________________ PC:_______________
Other: _____________
Phone: _________________________________________________
Pet Information:
Dog
___Male
___Rabies Tag #: ____________Clinic:_________________________
Cat
___Female
___Spayed/Neutered
Name: __________________________________
Breed: _____________________________________
Colour: _________________________________
Date of Birth:________________________________
Medical Records Provided
_____No
_____Yes
Agreement:
• By leaving this animal with the Northern Lights Regional Humane Society, I am relinquishing all rights of ownership.
• I understand that by relinquishing ownership of this animal, I will not be able to determine its final placement. I understand
that the placement options include adoption, foster home while awaiting adoption, transfer to breed appropriate animal
rescue, or (under certain circumstances) humanely euthanized. NLRHS can not guarantee that any animal will be
adopted.
• I understand that if I seek to reclaim this animal, I will have to go through the regular adoption procedure.
• To the best of my knowledge, this animal IS NOT sick and HAS NOT bitten anyone within the past ten (10) days.
• I also affirm that I am the legal owner of this animal and have not taken this animal from another person without that
person’s consent.
The amount of the non-refundable surrender fee for this animal is: _________________________________
IMPORTANT NOTICE: This Agreement is not complete until this document is signed by you, the non-refundable
surrender fee is paid in full, and this document is signed by an authorized VCHS representative. UNTIL SUCH
TIME AS THESE CONDITIONS ARE MET, YOU REMAIN THE LEGAL OWNER OF THE ABOVE-DESCRIBED
ANIMAL.
_______________________________
Signature of Pet Owner
_________________
Date
___________________________________
Signature of NLRHS Representative
Northern Lights Regional Humane Society
Box 481, 9702 – 97 Street
High Level, Alberta T0H 1Z0
Email: [email protected]
ANIMAL SURRENDER QUESTIONNAIRE
Are Shots Up to Date?
Y/N
Clinic: ______________________________________
How long have you owned this pet? __________ Months Years
Special Needs:
________________________________________________________________________________
________________________________________________________________________________
Bad Habits:
_________________________________________________________________________
Advice for New Owner:
________________________________________________________________________________
________________________________________________________________________________
Has the animal bit a person:
Y
N
If yes please describe what happened:__________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________