Placement Requests

Please complete this form with as much detail as you can. The undersigned hereby delivers to Old Dogs Go To Helen (“Rescue” or “we”) the following dog. Old Dogs Go To Helen will assume ownership over the following dog. Please note - our policy is that unfortunately once your dog is surrendered you will not receive personal updates or ashes returned once they have passed.

Owners Name*

Email*

Phone*

Animals Name, Type, Age & Spayed / Neutered - Yes or No?*

Good with Dogs, Cats and Kids ? *

Has this dog ever bitten or shown any aggressive tendencies? YES / NO If yes, to whom, and under what circumstances?*

Reason for re-homing *

Medical or behavioral problems (please specify):*

I, have read over the details for surrendering below. *

Medical Records

Attachments (0)

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Old Dogs Go To Helen

Please Read

The undersigned agrees that he/she is the owner, or authorized agent for the owner, and that the animal is in good physical condition, has no diseases or infections, is not vicious, and does not have a history of biting or attacking people. Any exceptions to these statements will be noted in the “Medical or behavioral problems” section above.

The undersigned hereby delivers possession and ownership of the animal to Old Dogs Go To Helen; releases Old Dogs Go To Helen from any and all claims, demands, and causes of action with respect to ownership of the animal.

The undersigned intends to convey full, complete, and unrestricted legal ownership of the animal to Old Dogs Go To Helen by execution and delivery of this Pet Surrender Form. Old Dogs Go To Helen will assume complete ownership over the animal and be solely responsible for all medical decisions, including vaccinations, surgery, medical procedures, and euthanasia if necessary due to illness or injury.

The undersigned further agrees to indemnify, defend, and hold harmless Old Dogs Go To Helen and anyone assisting Old Dogs Go To Helen from any liability, loss, claims, demands, causes of action, or damages (including

attorney fees) that such person may incur or sustain by reason of acceptance of the animal or any breach of this Pet Surrender Form by the undersigned.

I hereby relinquish all claims of ownership of the animal described above to Old Dogs Go To Helen. To the best of my knowledge, this animal has never seriously bitten anyone or exhibited aggressive tendencies, except as disclosed above.

All statements made above are truthful to the best of my knowledge. I have read the above and confirm that I am voluntarily transferring ownership of my dog to Old Dogs Go To Helen without reservation and with no conditions attached.