Canine Surrender Form

Dog's Name

Dog's Age

Breed

Color/Markings

Dog's Sex

Spayed/Neutered

Microchipped? Microchipped? Yes No

If yes; microchip number

Surgery tattoo? If “yes”; where?

How long have you had your dog?

Owner Name

Owner Address

Email

Phone

Why are you surrendering?

If the reason is behavioral or medical, please explain any actions you have taken to try to resolve the issue

Is there anything our organization can do that may help you keep your dog?

Where did you get your dog from?

If a breeder or rescue, what is the name and location of the person/organization?

Have you attempted to return your dog to where you got it from? Have you attempted to return your dog to where you got it from? Yes No

If “yes”, what was the reason that they did not take it?

Have you contacted any rescue groups to try to re-home your dog? Have you contacted any rescue groups to try to re-home your dog? Yes No

If “yes”, what was the reason they did not take your dog?

How many hours a day is your dog left alone?

How does your dog handle being left alone?

How many hours a day does your dog interact with people?

Where does your dog stay when you are not home?

Where does your dog spend its time when you are at home?

How is your dog confined to your property when outside? (physical fence, invisible fence, leash/tie, kennel, etc.)

Where does your dog sleep at night?

Is your dog housetrained? Is your dog housetrained? Yes No

If “no”, please explain when and where your dog has accidents inside the house:

Have you addressed this with a vet or trainer? Have you addressed this with a vet or trainer? Yes No

Is your dog crate trained? Is your dog crate trained? Yes No

Who takes care of your dog if you have to be away from home?

How does your dog react to you being away?

Is your dog allowed on furniture? Is your dog allowed on furniture? Yes No

When you need to remove your dog from furniture, please explain how you go about it and how your dog reacts

Is your dog allowed in the kitchen when food is being prepared? Is your dog allowed in the kitchen when food is being prepared? Yes No

If “no”, what is the reason why?

If “yes”, does your dog beg or “counter surf”? If “yes”, does your dog beg or “counter surf”? Yes No

When you need to remove food from your dog, please explain how you go about it and how your dog reacts

Please list any commands that your dog knows

Please list any special training equipment used

Does your dog run after cars, people, or other animals? If “yes”, please explain in as much detail as possible

How does your dog handle being in the car?

Does your dog get into trash or get into mischief when left alone?

Does your dog walk well on a leash?

Is your dog possessive or protective of anything (toys/food/items/people)? Please explain

Does your dog allow handling of all of its body parts? If “no”, please explain which parts you cannot handle and what your dog does when you try to handle them:

Does anything frighten your dog? Please explain in as much detail as possible:

Please describe your dog’s behavior around other dogs

Would you recommend us placing your dog in a home with other dogs? Why?

Has your dog lived with any other animals aside from other dogs? If “yes” please explain what animals and how your dog interacted with them

Has your dog lived with children? If “yes” please list ages

If “no” has your dog ever been around children? Please explain circumstances and how your dog interacted with them

Will your dog allow handling by children under the age of 6? Will your dog allow handling by children under the age of 6? yes no unsure

How does your dog react to unwanted handling by children?

Has your dog ever bitten or snapped at a child? Has your dog ever bitten or snapped at a child? yes no

If “yes” please explain the circumstances

Would you recommend that your dog be placed in a home with children, and why?

Has your dog been to the veterinarian? Has your dog been to the veterinarian? Yes No Unsure

When at the vet are there any treatments or handling that your dog will not allow?

Does your dog require any medications to visit the vet?

If “Yes” what medications?

Has your dog ever needed sedation for treatments at the vet’s office?

Does your dog need to wear a muzzle at the vet? Does your dog need to wear a muzzle at the vet? Yes No n/a

Has your dog ever been to the groomer? Has your dog ever been to the groomer? Yes No Unsure

Is the groomer able to perform all needed treatments on your dog?

Does your dog have any favorite types of toys?

What kind of exercise does your dog like (fetch/walks/hiking)?

Are there any toys your recommend that we do not give your dog, and what is the reason?

With adult family members, has your dog ever: With adult family members, has your dog ever: Growled Snapped at Bitten None

If yes, please explain their behavior toward adult family members

With child family members, has your dog ever: With child family members, has your dog ever: Growled Snapped at Bitten None

If yes, please explain their behavior toward child family members

With strangers at the door, has your dog ever: With strangers at the door, has your dog ever: Growled Snapped at Bitten None

If yes, please explain their behavior toward strangers

With visiting adults, has your dog ever: With visiting adults, has your dog ever: Growled Snapped at Bitten None

If yes, please explain their behavior toward visiting adults

With visiting children, has your dog ever: With visiting children, has your dog ever: Growled Snapped at Bitten None

If yes, please explain their behavior toward visiting children

With the vet or groomer, has your dog ever: With the vet or groomer, has your dog ever: Growled Snapped at Bitten None

If yes, please explain their behavior toward the vet or groomer

With people around your dog's food or toys, has your dog ever: With people around your dog's food or toys, has your dog ever: Growled Snapped at Bitten None

If yes, please explain their behavior with food or toys

With people around your dog's crate or bed, has your dog ever: With people around your dog's crate or bed, has your dog ever: Growled Snapped at Bitten None

If yes, please explain their behavior with their bed or crate

Has your dog ever bitten a person? Has your dog ever bitten a person? Snapped, no contact Minor bite, no blood draw Major bite, broke skin Other My dog has never bitten a person

Please explain the circumstances surrounding a bite to a person

Has your dog ever bitten another animal? Has your dog ever bitten another animal? Snapped, no contact Minor bite, no blood draw Major bite, broke skin Other My dog has never bitten another animal

Please explain the circumstances surrounding a bite to an animal

Please tell us what you love most about your dog

If during their first 7 days in our care, we find your dog to be unable to be adopted out due to a behavior or medical concern, would you be willing to redeem them?

I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in this application may render me civilly liable. I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in this application may render me civilly liable. Yes, I have answered to the best of my ability

Please type your full name and date as your electronic signature