Create Account or Log In:
Creating an account or logging in via facebook/email will let you save your application, and allow you to access your pets medical records and other important information after you adopt or foster.
Driver's License or other Picture ID number:
Are you requesting to surrender:
Why do you want to surrender this animal(s) to Polk County Humane Society?
Is this a litter? If so, how many in the litter? And, please give info on all pets in the litter below.
Pet's Name
Pet's Gender
Pet's Breed (or your guess of its Breed)
Pet's Size
Pet's Age
Description of Pet (color, fur length, type, ears, tail, etc.)
How long have you had this pet?
If this pet is a stray, when (date and time) did you find it?
If this pet is a stray, where did you find it? Please be as specific as possible. That will help us try to locate an owner.
If this pet is a stray, what efforts have you made to find its owner?
Please upload a picture of the pet here.
If this pet is NOT a stray, when & how did you come to possess the pet?
Pet's Diet (check all that apply)
How much have you been feeding? And, how often?
Is this pet neutered/spayed?
Has the pet had any vaccinations? If so, please describe.
Has the pet had any flea/ tick preventative administered? If so, what type and when?
Has the pet had any heartworm preventative administered? If so, what type and when?
Does this pet have any allergies that you know of?
Does this pet have any current or past injuries or illnesses? If so, please describe.
Is this pet on any medications? If so, what medications and how often are they administered?
Is this pet microchipped?
Would you describe the pet as: (check all that apply)
Where has this pet been living?
Does this pet have any of these qualities? (check all that apply)
This pet:
What activities does this pet enjoy?
What commands or tricks does this pet know?
Does this pet get along with? (check all that apply)
Is there any other information we should know about this pet if we are able to take them into our Shelter?
This animal:
If this animal has bitten or injured a person or persons in the past, please describe the number of times and circumstances.
Polk County Humane Society offers a Foster in Place program. With the Foster in Place program, you surrender the pet and then foster it until PCHS either has room or the pet is adopted. In the meantime, you would bring the animal in for vaccinations, preventatives and a neuter or spay surgery, if needed. PCHS provides food and supplies for fosters. The pet would be posted for adoption and you would need to be willing to meet potential adopters at the Humane Society. It is work on your part to foster in place, but if you are interested in the program, please indicate that below. The surrender fee of $25 or $50 still applies and there is additional paperwork for the Foster in Place program.
Are you interested in the PCHS Foster-in-Place Program?
I certify that the information included in the surrender request form is accurate and true. I understand that if I failed to tell the truth about the animal(s) that I wish to surrender, I could potentially endanger the safety of a staff person or another pet at Polk County Humane Society (PCHS).
I understand that if the staff at PCHS finds that the animal surrendered is exhibiting aggressive behavior, is feral or is unadoptable, PCHS reserves the right to return the animal back to the surrender (name on form) or person responsible.
I understand there is a fee of $25 per pet or $50 per litter due at the time of surrender.
If this animal or litter is accepted for surrender by PCHS, I agree that I am voluntarily surrendering the animal. To my knowledge, no other person has any rights or owns this animal. I hereby surrender all rights to this animal and I understand the animal will not be returned to me.
Signature / Date
Create Account or Log In:
Creating an account or logging in via facebook/email will let you save your application, and allow you to access your pets medical records and other important information after you adopt or foster.