Pet Legacy Program

First Name

Last Name

Phone

Address

City

State

ZIP

Date

Pet Name

Pet Type

Dog Cat Pocket Pet

Breed

Approximate Weight

Color

DOB

SEX

M F Unknown

Fixed

Yes No Unknown

Microchip

Yes No Unknown

Up to Date on Vaccines?

Yes No Unknown

Attach Vaccine Record

How long have you had your pet?

Where did you acquire your pet?

Vet Name

Vet Phone

Is your animal current on Heart-worm/Flea Prevention? If so, list below and attach medical records

Yes No Other

Medical Records

Does your pet have any current or past health conditions or injuries? If so-list below and attach medical records

Has your pet ever shown signs of aggression?

Yes No

If yes, was it provoked? Please explain

Does your pet live Indoors, Outdoors or both?

Indoors Outdoors Both

What type of food does your pet eat?

Any destructive habits?

Yes No

If yes, explain:

Is your pet house broken / Litter trained?

Yes No

Obedience Training?

Yes No

Please tell us about your pet and any special characteristic personality traits, or special needs:

Please tell us about the type of family your pet would be best suited for? (ie. other pets in the house, only pet in the house, children, etc.)

Statement of Pet Legacy Program

I certify that I

Do own the animal described above Do NOT own the animal described above

I hereby give all interest to the Gulf Coast Humane Society upon my passing. I have notified my family and the executor of my estate.

I understand that the Pet Legacy Program is a program that is at no cost and required regular communication with the Gulf Coast Humane Society regarding the health and well-being of my pet. I also understand that it is my responsibilty to inform my family members, executor of my estate, or other persons about the Pet Legacy Program.

There is no minimum set time for holding this animal. The holding time depends on the animal’s health, behavior and adoptability. It is also agreed that neither said society nor its management and employees shall incur any obligation to me on the disposition of the above listed animal. I certify that this animal has not bitten another animal or human within the last 10 days. I have read and understand that I have surrendered my rights and interest towards this animal.

Signature

Date

** To learn more about our Planned Giving Legacy Society, please click here. **

Statement of Pet Legacy Program

To learn more about our Planned Giving Legacy Society, please click here.