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Name of Westie being released to WRT: _________________________________

Age: ______ Sex: M F Neutered/Spayed? Y / N

Intake Form completed? Y / N

Name(s) of Owner(s) of released Westie (print):


Address: _________________________________________________________

City: ________________________ State: _______________ Zip: ___________

Phone Numbers: Home ____________ Cell ____________ Work ____________

Cell ____________ Work ____________

Terms of Agreement

Please read, sign and date the following statement:

I, _________________________, hereby make available for adoption the West Highland White Terrier (Westie) known as ______________________________.

I certify that I am the legal owner of this dog, free and clear of all other interests.

I certify that this dog does not have any dangerous propensities, and that I have not willfully concealed information about the dog that might indicate such propensities. The information I have provided about this dog is true and complete.

I hereby forever release, discharge and agree to hold harmless and indemnify Westie Rescue of Tennessee and the new adoptive owner and his/her family from all claims, demands, actions, causes of action or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above-named dog.

________________________________ _______________________________

Signature of Owner Signature of Co-Owner

________________________________ _______________________________

Date Date

By ______________________________ Date ___________________________

Westie Rescue of Tennessee (signature)