Pet Surrender Form Please complete this form if you are wanting to surrender your pet. Please complete the online form provided by Belly Rub n Grub, before submitting. Please Note:One form must be filled per surrendered pet.Pet Owners Information(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Relinquishment of the PetI hereby relinquish and release custody, to the following nonprofit 501(c)3 animal rescue: Belly Rub N Grub Nonprofit animal rescue located in Lancaster, California. Pet InformationType of Pet:(Required) Dog Cat Pet Gender:(Required) Male Female Current on Vaccinations:(Required) Yes No Pet DescriptionName(Required) Enter Pet's Name Date of Birth:(Required)Color(s) of the Pet(Required)Distinct Markings(Required)Hair Type:(Required) Hairless Short hair Medium hair Long hair Age:(Required) 0-12 Months 1-5 Years 5-10 Years 10-15 Years Over 15 Years IMPORTANT NOTE:You must provide a Spay or Neuter Certificate, in order to qualify for the Belly Rub n Grub Pet Surrender Program.Who is the Micro-chip Company?(Required) Home Again Pet Link Pet Key AKC CAR AVDID ResQ ALLFLEX Peeva Other Is the Pet Micro-Chipped?(Required) Yes No Provide Micro-chip #:(Required)Vaccinations:(Required) Yes, and I will bring them with me Some, and I will bring what I have No vaccinations Other Pet Health:For us to be prepared to provide your pet with the necessary care, please inform us of any special needs this pet may have pre-existing medical conditions, such as, but not limited to: Select one or more.. Seizures Diabetes Heart Worms Cancer Separation Anxiety FIP FeLV Select one or more.. Feline Herpes Virus Chronic Kidney Disease Hypothyroidism Distemper Parvo Virus Dog Flu Select one or more.. Cat Flu URI Ticks Fleas Ringworm Mange Select one or more.. Scabies Cancer Allergies Zoonotic Infections Arthritis Special Considerations:Please let us know if your pet is on any of the following: Select one or more.. Medications Vitamins Specialty Foods Anti-Depressants Select one or more.. Flea Preventative Tick Preventative Heartworm Preventative Other Please elaborate..(Required)Veterinarian Information.Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last PhoneEmail Tell us more about the pet...Is the pet good with cats?(Required) Yes No Is the pet good with small dogs?(Required) Yes No Is the pet good with large dogs?(Required) Yes No Does the pet get along with:(Required) Infants Toddlers Pre-Teens Teens Young Adults Can this pet co-habitate with other pet's of the same house?(Required) Yes No Is your pet aggressive?(Required) Yes No What type of agression?(Required)Select any that pertain to your pet Fear Loud Noises Possessive Predatory Frustration Pain Nothing applies to my pet What type of agression?(Required)Select any that pertain to your pet Genetics Illness Pregnancy Maternal Hypothyroidism Aging Nothing applies to my pet What type of agression?(Required)Select any that pertain to your pet Anxiety Jealousy Competitiveness Seizures Brain Trama/ BrainTumor Resource Guarding/Territorial Nothing applies to my pet Other If agression is not listed, please explain here, in this text boxAre there any warning signs to the agression?(Required) Yes No Please explain..(Required)Is the aggression directed at a certain person or animal?(Required) Person Animal Please explain..(Required)Have you consulted with a:(Required) Trainer? Behavioralist? Veterinarian? Other What was there advice?Is your pet...(Required)Please check the box when it applies to your pet. Leave blank, if not. Trained to walk on a leash Potty/Litter Box trained My pet has "accidents" How long have you had your pet?(Required)Please include Month/YearDid you get the pet from a...(Required)Please select from the following Rescue Facility? Animal Shelter? Breeder Family/Friend Stray/Found Other Did you attempt to take the pet back to the rescue or shelter? Please explain..(Required)The reason you are surrendering the pet?(Required)Please select from the list. If none apply to your situation, please select "other" and explain. Financial reasons Moving/Change with living conditions Medical reasons Allergies I no longer have time for a pet I don't want to have a pet Other Reason for surrendering (continued)(Required) Not what I expected Didn’t do my research on this breed Doesn’t get along with my other pets Sprays/Has accidents Have not trained/out of control Aggressive Other Alternatives to Consider..Is there something we can help you with so you can keep your pet?(Required) Yes No Great! How can we help? Resources (visit our Resource page) Guidance Information Food Medical Need temporary fostering (Provided, if available) Date MM slash DD slash YYYY Name of owner surrendering pet Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last ConsentTo help us not incur additional costs and more importantly to maintain the safety of our current rescue animals, as well as our own pets, BEFORE SURRENDERING YOUR PET, we require that they be tested at the vet/clinic for contagious and/or fatal diseases. Feline SNAP and Canine 4DX SNAP tests, Parvo test, as well as fecal test for Giardia, Coccidia and parasites. We can’t take any chances with theses diseases spreading and running rampant within our animal communities. Please BRING PROOF of NEGATIVE tests/results, along with vet/clinic information where tests were done for confirmation. Thank you for your help and understanding. The Fee to surrender a pet is $150 for the first pet, $50 for each additional pet. This fee is to help us with some intake costs, such as food, vetting and other necessities. I agree to all of the terms and conditions as stated in this Surrender FormNameThis field is for validation purposes and should be left unchanged. Δ