Audrey's Safe Haven Dog Surrender Form

Name: *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email *

example@example.com

Date: *

Date

Animals Name: *

Age

Breed *

Upload a picture of your dog. *

Browse Files

Check the corresponding boxes to inform Audrey's Safe Haven Canine Behavior Specialist as to whether or not your pet has any behavioral concerns worth noting or working on with a professional trainer while in the Audrey's Safe Haven or in foster. Any items marked Yes will be worked on with a trainer. Any items marked Maybe will be evaluated. Please use the back of this sheet to elaborate on any items which you think require additional information

Is your dog an escape artist? *

Yes No Unknown

Does your dog struggle to be confined (in a crate)? *

Yes No Unknown

Is your dog reactive to seeing people when on leash? *

Yes No Unknown

Is your dog reactive to seeing dogs when on leash? *

Yes No Unknown

Is your dog destructive in the home? *

Yes No Unknown

Does your dog get anxious in the car/carsick? *

Yes No Unknown

Is your dog potty trained? *

Yes No Unknown

Is your dog protective of their food? *

Yes No Unknown

Is your dog protective of their toys? *

Yes No Unknown

Is your dog protective of their bed/space? *

Yes No Unknown

Is your dog protective of their siblings (if any)? *

Yes No Unknown

Is your dog protective of their handler? *

Yes No Unknown

Is your dog okay with children 0-2? *

Yes No Unknown

Is your dog okay with children 3-5? *

Yes No Unknown

Is your dog okay with children 5-8? *

Yes No Unknown

Is your dog okay with children 8-12? *

Yes No Unknown

Is your dog okay with children 12+? *

Yes No Unknown

Has your dog ever lived with other dogs? *

Yes No Unknown

Has your dog ever coexisted with dogs smaller than them? *

Yes No Unknown

Has your dog coexisted with dogs larger than them? *

Yes No Unknown

Has your dog ever inured a dog? *

Yes (provide detail) No Unknown

Has your dog ever lived with cats? *

Yes No Unknown

Has your dog ever injured a cat? *

Yes No Unknown

Has your dog been fearful of children? *

Yes No Unknown

Has your dog been fearful of men? *

Yes No Uknown

Has your dog fearful of women? *

Yes No Uknown

Has your dog enjoy playing with toys? *

Yes No Unknown

Has your dog enjoyed treats? *

Yes No Unknown

Has your dog ever injured a person? *

Yes (explain) No Unknown

Notes/Reason for Surrender *

Relinquishing Receipt for Animal Surrendered to Audrey's Safe Haven by Owner *

I hereby give Audrey's Safe Haven permission to request all medical history and medical records from my Veterinarian for the animal I am relinquishing. I acknowledge that my signature on his receipt relinquishes all claims of ownership of the animal(s) described. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, suites, or otherwise against Audrey's Safe Haven Animal Control with respect to this animal(s). I understand that the Audrey's Safe Haven Control will not return this animal to me, once left in its care, under any circumstances, unless otherwise approved by the Audrey's Safe Haven Director.

Signature *

Clear

Behavior Checklist