Small Mammal Surrender Application_24Pet Owner InformationPet Owner Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (please include area code)*Have you adopted from, donated to, or surrendered another animal to Wayside Waifs in the past?*-YesNoAre you the owner of this pet? If not, what's your relationship with the owner?* Pet's Description/InformationPet's name:* Pet's age:* Pet's species:* Gender:*-MaleFemaleUnknownIs this pet spayed or neutered?*-YesNoUnknownDescribe this pet's color/markings:* Where did you get this pet:*Found strayBreeder or Pet StoreFamilyFriend/Acquaintance/Co-worker/NeighborAdopted from Wayside WaifsAdopted from another shelter/rescue (list below)Born at homeGiftInternet listingOther (list below)If other, please explain:If you chose "Adopted from another shelter/rescue", which organization? Have you tried reaching out to that shelter/rescue? Yes No How long have you owned this pet?* What is the main reason you are surrendering?* Aggression Destructive Health of pet Heath or Death of Owner Moving, Landlord, and/or Housing challenges Allergies Found Stray - Cannot Keep Too Many Pets Financial/Cannot Afford How long can you continue to safely care for the pet?*Are you interested in troubleshooting options to keep your pet in the home?*YesNoMaybePet's Medical InformationName of vet clinic you use:* Does your pet have any ongoing or current medical concerns?*YesNoUnknownIf Yes or Unknown, please describe:Has your pet been diagnosed with anything by a veterinarian?*-YesNoUnknownIf yes, please describe:Is your pet taking any medication and/or on a special diet?*-YesNoIf yes, please list medications or prescribed diet:General QuestionsPlease describe the current diet and food preferences:*Describe how this pet is housed (ex: large, medium, small cage, free-roaming in room, etc.)*Is this pet litterbox trained?*-YesNoHow does this pet behave when being handled by people?*Your pet has lived with:*-Adult(s)Children (age 0-6)Children (age 6-12)Teenagers (age 12-18)DogsCatsOther species small mammal petsSame species petsIs this pet bonded (has a very close, almost inseparable relationship) with another pet in the household?*-YesNoHas this pet ever bitten a person?*YesNoMaybeDid the bite draw blood?YesNoDate of the most recent incident? Month Day Year Describe the incident(s) using as much detail as possible:Please feel free to add any additional comments that you think would be helpful for the shelter staff and/or a potential adopter:Household Safety/Wellness InformationHas anyone ever threatened to harm/harmed your pet(s)?*-YesNoHas anyone ever threatened to harm/harmed you?*-YesNoDo you feel safe in your home?*-YesNoPlease upload (1) image of your pet. Image should be in focus and show the animals face and body.Max. file size: 50 MB.Upload Image PhoneThis field is for validation purposes and should be left unchanged.