Release/Surrender Form

Description of Siberian Husky, hereinafter referred to as "dog":

Registered Name (if available):			AKC Number (if available):
Call Name:	Sex:	Age:	Eye Color:	Coat Color:

Health and History Information:

Breeder's Name (if Known):
Breeder's Address:
Vet's Name and Address:
Date of Current Shots:	Has the dog ever been bred?
Heartworm? (has dog been tested?):	On preventative?:
Housebroken?:	Obedience trained?:
Prefers men or women?:	Good with children?:
List Bad Habits:
If the dog has bitten a human being or animal, give particulars:
Reason(s) for surrendering this dog:

I/we hereby state that I/we are the sole owner(s) of the above-described dog and that there are no other parties that may have a legal interest in this dog. I/we hereby surrender all of my/our interests and ownership rights in such dog to the Rescue Program and hereby relinquish all claims to such dog. I/we understand that such surrender and release of my/our ownership rights in this dog is irrevocable. I/we state and affirm that to the best of my/our knowledge, the said dog has not bitten any human being or animal unless full disclosure is made above. I/we understand and agree that if I/we have not made full disclosure about any known bites, I/we agree to hold the Rescue Program harmless and indemnify the Rescue Program for any damages resulting from the dog's undisclosed propensity to bite. I/we understand and agree that I/we am/are surrendering this dog to the Rescue Program of my/our own free will and that such surrender and/or release does not constitute a sale. I/we further understand and agree that I/we will receive no money or other compensation as a result of surrendering this dog but that I/we have received a benefit from this surrender in that I/we can no longer care for this dog.

Such release is executed this ____________ day of _________________, 20__

________________________________________________ Signature of Owner	______________________________________________________ Signature of Co-owner
________________________________________________ Address	______________________________________________________ Address
________________________________________________ Telephone	______________________________________________________ Telephone
Release/Surrender Donation_________________________