Animal Surrender Request Form

ACHS can only accept surrenders if there is space at the shelter. We are currently at full capacity and will add you to our wait list. An ACHS representative will contact you when we have an opening and schedule an appointment for you to bring your pet to the shelter.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Township *

Owner: I certify I own the animal listed below and I hereby surrender all my interests therein to the Adams County Humane Society. It is expressly agreed that said ACHS, including its officers and employees, will not incur any obligation to me on account of such disposition of said animal. I certify that said animal has/had not bitten any other animal or human within the past fourteen (14) days. I understand every effort will be made to find my pet a good home, but the said animal below may be euthanized if ACHS finds it to have what they consider a major health issue or aggression issue. The pet will not be euthanized for space or time.

Type in your name as a temporary signature. *

Animal Information

Cat or Dog? *

Male or Female and Age *

Name of Animal *

Age *

Breed and Color *

Is your pet spayed or neutered? *

Is your pet up to date on the Rabies vaccination? *

Is your pet microchipped? *

Comment *

Signatures will be completed at your scheduled surrender appointment.

Owner Signature & Date *

ACHS Representative Signature & Date *

Submit