Request to Surrender

Please use this form for any dog that you are requesting to surrender to UYR. Surrendering your dog is an irrevocable decision; once surrendered, you release your rights as a pet owner. UYR does not return or readopt dogs to the surrendering owner. Our Foster Coordinator will determine if we have an appropriate home to accommodate your dog's needs. A representative from UYR will be in contact with you as soon as possible. This form must be completed in its entirety before we can consider accepting your dog into UYR.
Your Name:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Alternate Phone Number:
Email Address:
Dog Name:
Dog Age:
Date of Birth:
Gender:
Weight:
Photo of Dog:	Delete?
Breed:
Reason for surrender:
Any health issues:
Care currently given for these issues:
Last Vet Visit:
Vet Name and Number:
Vet Fax Number:
May we contact your vet:
Up to date on shots:
Rabies Vaccination:
Rabies Date Done:
Parvo/Distemper:
Parvo/Distemper Date Done:
Bordetella Vaccination:
Bordetella Date Done:
Heartworm Test Done:
HW Date Done:
HW Prevention Used:
Fecal Test Done:
Spayed/Neutered:
Is there anything else we should know about this dog:
Gets along with children:
Gets along with other dogs:
Gets along with cats:
Has dog ever bitten:
Explain bite situation:
Is dog housetrained:
If no, please explain:
UYR is dependent on donations to give the needed care to our rescues.
Are you willing to make a donation to help with these costs:
If so, how much:	$
How did you hear about UYR:
Have you contacted other groups, if so explain:
May we refer your request to another reputable group if we have no one to help you: