I have read and agree to all of the following:

1. I certify that I am 18+ years old.

2. I am the legal owner or duly authorized agent for the owner of the pet described above. I hereby give permission for my pet to be humanely put to sleep (euthanized) at West Valley Humane Society by the veterinarian, the veterinary technician, or the licensed euthanasia technician on duty.

3. I have been advised as to the nature of the procedure and understand that my pet will be humanely put to sleep.

4. I understand that all cats must arrive in carriers and dogs must arrive with a well-fitted collar/harness and a leash.

5. I understand that I can request carriers, collars, leashes, etc. back by notifying WVHS staff at my scheduled appointment.

6. I understand that payment is due in full before services will be rendered by WVHS. I further understand that all payments are final. Refunds will not be issued for any reason by WVHS.

7. I understand that I can opt for the shelter to dispose of my pet, receive the body of my pet back for burial, or receive my pet's ashes depending on services indicated on this form. I agree to pick up my pet's remains at the time specified and I understand that if I fail to do so, I will be liable for storage fees. I also authorize WVHS to dispose of my pet's ashes if I fail to pick them up within 2 weeks of notification that they are ready for pick up.

8. I agree to indemnify and hold harmless the West Valley Humane Society, the attending veterinarian, and any of the officers or employees of said entity from any and all claims, damages and causes of action that may arise from the procedures or operations to be rendered.

9. I understand that the attending veterinarian or WVHS employees for various reasons may decline my pet for euthanasia.

10. I understand that I am relinquishing ownership of my pet to WVHS.

11. I understand that if my pet is declined for euthanasia services I may not receive my pet back in my possession. If the animal is placed available for adoption, I may fill out an application seeking to adopt the pet, but the application may be declined at the discretion of WVHS staff.

12. I agree to indemnify and hold harmless West Valley Humane Society, the attending veterinary, veterinary technician, and any other WVHS employees from any and all liability arising out of the performance of all procedures during my visit.