Canine Relinquishment Form

Owner Relinquishment Form - Canine

Please first call 719-395-2737 to discuss relinquishment of your dog before filling out this form.
  • Dog Information

  • MM slash DD slash YYYY
  • Behavior

  • Pet's Medical Information

  • Surrendering Party Information

  • Max. file size: 64 MB.
  • By signing your name below, you give up all rights to the animal and surrender him/her to Ark-Valley Humane Society. Ark-Valley Humane Society is a minimal euthanasia facility, however we do euthanize animals when they do not fit our criteria for adoption. Our policies on euthanasia are aimed at protecting our staff, volunteers, potential owners, animals at the shelter, this animal, and the community at large. If you have specific questions about our policy, please ask an Ark-Valley Humane Society employee. Ark-Valley Humane Society is not obligated to disclose if an animal is euthanized, adopted, or transferred. I certify that I own this animal or am acting as agent for the owner. If I am acting as agent for the owner, I certify that I have permission to surrender this animal and to relinquish all ownership rights of the animal on behalf of the owner. I certify that the said animal has not bitten anyone in the past 10 days. If the animal has bitten someone in the last 10 days, I am obligated to notify Ark-Valley Humane Society of the date and occurrence. I hereby relinquish all rights of ownership for this animal to the Ark-Valley Humane Society, Inc. and agree that the disposition of this animal be at the discretion of Ark-Valley Humane Society. I request that copies or summaries of the medical records for my pet be released to Ark-Valley Humane Society.
  • MM slash DD slash YYYY