Admission Form

To Surrender Your Pet

This form is a legal document that transfers ownership of the admitted animal to the Humane Society of Wayne County (HSWC) from the individual signing this form. We reserve the right to decide the length of stay and disposition of the animal. We request that any medical records you might have for this animal be submitted to the HSWC at the time of admission. No guarantee is made that any incoming animal will be adopted. This document is considered a confidential document and the only information that will be given out about the animal is whether or not it is at the HSWC Shelter. A copy of this document will be provided to you.

Please read the following three (3) statements carefully and check the lines for all that apply. I assume full responsibility for surrendering this animal to the HSWC Shelter because:(Required)

I guarantee that the surrendered animal is mine.

I have provided a copy of written permission from the owner to the WCHS authorizing the surrender of this animal.

This animal is a stray and I do not know who the owner is.

How long has this animal been in your custody?(Required)

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Signature(Required)

Date

Admission fee paid

HSWC ID#

Medical Records Received

Rabies Certificate

S/N Certificate

Vaccination Certificate

Fill Out the personality profile

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