Surrender Form

(This form can be used and modified as needed for your organization to gather information from individuals hoping to surrender a pet.)

If this is a stray dog you found, did you have him/her scanned for a microchip? (if yes, please enter chip number) If not, please have the dog scanned before filling out the form. Veterinary offices or animal shelters can scan for you. (just enter N/A if this doesn't apply to you).

First Name

Last Name

Address 1

Address 2

City

State

Zip

Primary Contact Phone

Dog's Name

Gender

Age

Is the dog up to date with shots? Please include dates of last shots given. Rabies, DHPP (distemper/parvo), Bordetella.

Do you have vaccine records?

Is the dog microchipped?

Please attach vaccine records.

What breed(s)?

Please attach pictures of the dog.

How long have you had the dog?

Where did you get the dog?

Why are you rehoming your dog?

Have you tried to resolve the issues? If so, how?

Any medical issues? If so, please elaborate.

Inside or outside dog? Or both?

Where does the dog sleep at night?

Is it good with SMALL dogs? Males and females?

Is it good with cats?

Is the dog good with men/women?

Is the dog good with children and babies?

Is it housebroken?

Is it obedience trained?

Is it protection Trained?

Has the dog ever bitten a human? (if yes, please give details)

Has the dog ever bitten another animal? If yes, please give details - include SIZE and GENDER of the other animal)

Does it walk well on leash?

Are you able to keep your dog until we find him/her another home?

Does it: BARK a lot? CHEW on things? JUMP fences? (if so, how high is fencing?) Please answer all the questions.

Anything else we need to know about your dog?

Submission of an application is not a guarantee that the pet will be accepted into our Rescue. In some cases, we may already have someone looking for a dog that would be a perfect match. We do our best to help as many dogs as we can, but we receive an overwhelming amount of pleas from owners asking us to take their dogs into our Rescue.

I understand