Owner Release Form
In order to find the most appropriate home for your dog, please provide as much detail as possible about his/her history, veterinary care, likes and dislikes, and behaviors. By providing this information you are ensuring the easiest transition for your pet, only you know them best. Behavior and medical issues do not necessarily create problems but not disclosing them certainly will. Please be truthful about your dog's situation so we can try to provide the best resources to them. If you are surrendering more than one dog, please fill out a separate form for each one.
I agree with, and understand, the above statement
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Yes
No
Section One - Owner's General Information
Owner's Name
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First Name
Last Name
Owner's Email
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example@example.com
Owner's Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Home Phone Number
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-
Area Code
Phone Number
Owner's Mobile Phone Number
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-
Area Code
Phone Number
Section Two - Dog's General Information
Dog's Name / Nicknames
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Dog's DOB / Approximate Age
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Dog's Breed or Best Guess
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Dog's Weight
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Dog's Color and Markings
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Gender
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Unaltered Male
Unaltered Female
Neutered Male
Spayed Female
Upload Photo of Dog
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Browse Files
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Section Three - Dog's History
Explain why you are surrendering this dog
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If we could help you resolve this issue, would you be interested in keeping this dog?
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How long have you owned this dog?
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What do you know of the dog's history prior to your ownership?
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Section Four - Medical
Has the dog seen a veterinarian at least once a year?
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Yes
No
Not Sure
Is the dog current on vaccinations? (rabies and distemper/parvo)
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Yes
No
Not Sure
Is this dog currently on heartworm prevention?
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Yes
No
Yes, but only in the warm months
Not Sure
Veterinarian's name, address and phone number (to obtain vet records)
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Has the dog ever been diagnosed with, or treated for, any of the following (check all that apply)
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Allergies
Epilepsy or Seizures
Bloat/GDV
Dilated cardiomyopathy
Wobbler's Syndrome
Hip or elbow dysplasia
Organ failure or dysfunction
Heartworm
Thyroid disease
Broken or fractured bones
Dental disease or broken teeth
Urinary issues, incontinence, or marking
Heart murmur
Hit by a car
Entropion/Ectropion or any eye issues or blindness
More than 1 ear infection
Fecal incontinence
Megacolon or megaesophagus
Any neurological concerns
Hearing impairment or deafness
No Medical Issues Apply
If diagnosed with anything medically or any of the above, please use this space to elaborate:
Does the dog have any lumps, bumps, wounds, scars, skin tags, or anything abnormal externally?
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Yes
No
If you answered "yes" to the above question, please explain the location, size, and any medical diagnosis (if any) related to it. Please list all lumps/bumps/wounds/scars/skin tags/etc.
List any any medications, supplements, or special diets that your dog needs.
What are you currently feeding your dog? Please list the brand of the food.
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How often do you feed the dog and how much do you feed them per meal?
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Section 5 - Behavior and Training
How would you describe the dog most of the time? (check all that apply)
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Very Active
Couch Potato
Talkative
Quiet
Playful
Friendly to Family
Shy to Family
Friendly to Visitors
Shy to Visitors
A Clown
Affectionate
Lap Dog
Fearful
Independant
More Like a Person
Fearless
Aloof
Withdrawn
Solitary
Other
Does the dog have any form of anxiety, such as separation anxiety or anxiety in general?
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Yes
No
Other
How does the dog like to play? (check all that apply)
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Plays gently, does not use teeth or claws
Likes to play rough, may bite or scratch
Likes to play ball
Likes stuffed toys
Likes to learn tricks for treats
Likes to play in or around water
Likes to play with dogs of all sizes
Prefers to play with larger dogs
Prefers to play with smaller dogs
Not much interest in play
Other
Does the dog have any favorite toys or activities? If so, please explain.
What level of energy does your dog have?
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High/puppy energy- runs and plays constantly
Moderate energy- runs and plays often
Mild energy- runs and plays occasionally
Low energy- very low energy indoors and outdoors
What sort of exercise do you provide your dog? (this is to help us determine what sort of foster home the dog may need)
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None
Mild- a walk once a week or less
Moderate- 2-4 walks per week
High- at least 5 walks per week or more
Other
What type of collar does the dog use for walks?
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What type(s) of training has this dog had?
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Obedience class
Home training
Professional
None
Other
Does this dog know the basic commands?(check all that apply)
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Sit
Stay
Come
Lie Down
Does not know basic commands
Needs work on basic commands
Does this dog know any tricks?
Section Six - Home and Human Interactions
How would you describe your household?
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Active
Noisy
Quiet
Average
What areas of your home did the dog have access to? (check all that apply)
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Inside house with access to outside
Inside at night
Indoors in cold weather
Barn or shed
Outdoors only
Garage or basement
Screened Porch
Outdoors in warm weather
Where does the dog spend most of his/her time? (check all that apply)
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Bedroom
Kitchen
Living Room
Where people are
Outdoors
Barn/shed
Crate
Garage or basement
Other
Is your yard fenced?
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Yes
No
If your yard is not fenced, how have you kept the dog confined to your property?
Has the dog repeatedly escaped from the yard?
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Yes
No
Other
If the dog escapes from the yard, how does the dog escape?
Digs out
Chews through
Jumps fence
Opens gate
Charges gate when open
Other
Is the dog crate trained?
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Yes
No
Not sure
Is the dog destructive if left alone with free roam of the room/house?
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Yes
No
Other
Where do you leave the dog when no one was home?
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How many hours a day, on average, does the dog spend unsupervised?
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Where is the dog used to sleeping?
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Owner's room
Owner's bed
Dog house
Garage/basement
Crate
Patio
Outside
Furniture
Other
What ages of people lived with the dog?
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Adult Men
Adult Women
Seniors
Garage/basement
Children, under 7 years old
Children, over 7 years old
Other
Is this dog most comfortable with:
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Women
Men
Kids
Teenagers
Seniors
Loves all people
Other
Has the dog regularly been around children?
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Yes
No
Not sure
If the dog lived with children, please provide the age of the children.
If this dog lived with children under age 7, how did they interact? (check all that apply)
Dog actively avoided children
Child could pet the dog
Dog & child played together
Dog growled at child
Ignored each other
Dog was afraid
Mutual adoration
Dog seemed snappy
Dog too much for small children
Other
Has the dog regularly been around children?
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Yes
No
Other
If no, please explain:
Section Seven - Animal Interactions
Has the dog ever been exposed to, or lived with, other dogs?
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Yes
No
Other
If this dog lived with children under age 7, how did they interact? (check all that apply)
Adored each other
Played with each other
Slept near each other
Avoided each other
Peacefully coexisted
Sniffed noses
Fought without injuries
Fought with injuries
Ate well together
Groomed each other
Rough with each other
Had to be separated at feeding
Other
Has the experiences with other dogs always been positive?
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Yes
No
Other
Has the dog ever been exposed to, or lived with, cats?
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Yes
No
Not sure
If the dog lived with cats, how did they interact? (check all that apply)
Adored each other
Played with each other
Slept near each other
Avoided each other
Peacefully coexisted
Cat rubbed on the dog
Fought without injuries
Fought with injuries
Caused the cat stress
Groomed each other
Rough with cat
Gentle with the cat
Other
Has the experiences with cats always been positive?
Yes
No
If no, please explain:
Has this dog ever bitten another animal?
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Yes
No
If yes, please describe the incident(s) and extent of injuries:
Is the dog frightened by anything? (check all that apply)
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Men
Children
Brooms
Thunder
Fireworks
Hats
Balloons
Vacuums
Large Trucks
Bicycles
Water
Hands
Feet
Appliances
Not Afraid
Other
Is your dog housetrained?
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Yes
No
How often does the dog have accidents in the house?
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Once a day
Once a week
Never
Every time the dog is inside
Does this dog chase anything?
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People
Children
Cats
Livestock
Cars
Bicycles
Skateboards
Wildlife
Nothing
Other
Is your dog a barker?
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Yes
No
If yes, please explain the circumstances
What other animals has the dog lived with? If they have lived with other dogs or cats, please provide if the other dog or cat is male or female and their age.
What other animals has the dog lived with? If they have lived with other dogs or cats, please provide if the other dog or cat is male or female and their age.
Dog (male)
Dog (female)
Cats (indoor)
Cats (outdoor)
Birds
Poultry/Livestock
Has not been around other animals
Other
What types of animals does the dog not get along with?
When leashed does this dog lunge at other dogs?
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Yes
No
When leashed does this dog lunge at other people?
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Yes
No
Has the dog ever tried to attacked or bite a person or animal?
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Yes
No
If you answered "yes" above, please explain
Are there any quirks or habits of the dog that you are not fond of?
Is there anything else we should know about the dog?
Tell us something you truly love about the dog.
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Section Seven - Signature
As of today's date, I certify that I am over 18 years of age.
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Yes
No
I certify that I am the lawful owner of this dog that I am surrendering
Yes
No
I certify by selecting yes that I fully understand and accept the terms and conditions of the Lola's Rescue Owner Surrender Agreement below
Yes
No
LOLA'S RESCUE, INC. OWNER SURRENDER AGREEMENT
It is understood that Lola's Rescue does not buy or pay for dogs. This is a service to help place dogs in new homes when their present owners can no longer keep them. This service is free, however a donation to help pay for expenses is greatly appreciated as we are a nonprofit rescue and rely heavily on our donors to continue saving the lives of the dogs that come into our care. Any amount, small or large, is helpful and can be made on our website or via check sent to 22351 East Bayaud Avenue, Aurora, Colorado 80018.
READ, ACCEPT AND DATE THE FOLLOWING:
I hereby make available for adoption, the dog named below on this form, to Lola's Rescue. I certify that this dog is not possessed of any dangerous or vicious 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 herby forever release, discharge and agree to hold harmless and indemnify the Lola's Rescue, its board of directors, its members, officers, and agents 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 named dog.
Print the name of the dog you are surrendering
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Owner Surrender Full Name as legal signature
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