Dog Owner Surrender Form - Windsor Essex County Humane Society
RequiredRequired Question(s)
The following questions provide us with information about how your pet behaved in different circumstances while he or she was living with you.  Your pet is likely to behave in similar ways in his or her new home.  This information will help us find the most suitable home for your pet and to effectively help their new family prepare for them. 
Your honesty and complete answers are necessary and appreciated.  This survey should take approximately 20-30 minutes to complete.  
Required 1.
Please enter your contact information below.

First Name:
Last Name:
Home Phone:
Email Address:
Address 1:
Postal Code:

Required 2.

Date that you are scheduled to surrender your dog, or the date that you surrendered your dog if you have already done so.

Please note that you will receive a $10 discount off your surrender fee if you complete this survey prior to your scheduled surrender appointment.


50 characters left.
Required 3.

What is your dog's name?


50 characters left.
Required 4.

How old is your dog?  If you're not sure, please estimate their age.


50 characters left.
Required 5.

What breed is your dog?  If you're not certain, please indicate "unknown".


50 characters left.
Required 6.

Is your dog:

Female and spayed
Male and neutered
Female and intact (not spayed)
Male and intact (not neutered)
Not sure
Required 7.

Why are you surrendering your dog?


350 characters left.
Required 8.

Where did you get this dog?

The Windsor/Essex County Humane Society
Friend or family
Newspaper/ web site
Found as a stray
Purchased from a pet store
Purchased from the breeder (please indicate breeder's name if known)
Other shelter or rescue (please indicate the organization's name if known)
Other or unknown (please provide details)
  • Comment:

  • 500 characters left.
Required 9.

How long have you owned this dog?


50 characters left.
Required 10.

What brand of food is your dog used to eating?


50 characters left.
Required 11.

How often is this dog used to being fed?

Once a day
Twice a day
Three times a day
I leave food out and he/she eats as they want to