CCFR Surrender Form

Date*

MonthDayYear
Date
Pet's Name*
Why are you surrendering or returning this pet?*
Are you*

surrendering this pet to CCFRReturning this pet to CCFR (proceed to the checked statements section if you've had this pet less than 6 months)
Are you the legal guardian of this pet?*

YesNo
How long have you owned this pet?*
Current Owner's Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Day time phone #*
Email*
example@example.com
What is the latest date you can keep your dog until?*

MonthDayYear
Date
Have you ever surrendered a pet to a shelter or rescue in the past*

YesNo
If Yes, please list the pet, where surrendered, and circumstances
Microchip registration number
Color/Pattern
Age*
Date of Birth

MonthDayYear
Date
Approximate weight of dog*
This dog is*

MaleFemale
This dog is*

spayed or neuteredunaltered
What breed(s) is this dog?*
Breeder or Where obtained (name, address, kennel, shelter)*
If you purchased this dog from a breeder or adopted this dog from a Rescue, did you sign a contract stating you would return the dog if you are unable to keep it?

YesNoUnsure
Veterinarian Clinic/Name*
Address
City
State
zip code
Vet phone*
Format: (000) 000-0000.
Date of last annual shots*

MonthDayYear
Date of last Vet visit*

MonthDayYear
Date of last Rabies vaccine*

MonthDayYear
Name of County
Rabies tag #
Date of last Bordetella vaccination*

MonthDayYear
Date of last Heartworm check*

MonthDayYear
Results of Heartworm test?*

NegativePositive
Has the dog ever been treated by a vet because it had heartworms?*

YesNo
If yes, please list date

MonthDayYear
What is the name of dog's Heartworm preventative he is currently on? Next dosage due on
Are you currently treating your dog for fleas?*

YesNo
If yes, what brand of flea product
Has your dog been or being treated for*

back problemsdiabetesCushing's diseaseAddison's diseaseEpilepsyother seizure disordersheart/cardiovascular issuesfrequent urinary tract infectionsobesitynoneOther
Does the dog require medication for any temporary or ongoing problem?*

YesNo
Does the dog suffer from allergies?*

YesNo
If yes, what is the dog allergic to?
Has your dog ever had a major injury or surgery? (broken bones, back injury, surgery other than neutering?) Please explain.*
Please list some of the dog's favorite games and toys (tug of war, fetch, etc)*
List any formal training (obedience, tracking, agility)
Have you (or anyone) ever used harsh corrections, an electronic, citronella, prong, or bark collar, or any other aversive training technique on this pet?*

YesNo
If yes, please describe
This dog has bitten a person before*

YesNo
If yes, please describe
It is important that you list any and all behavioral problems. We want your pet to go to a good, permanent and loving home. To do this, we need to know as much about its good and bad traits as possible. How is the dog's temperament around:
Other dogs?*

GoodFairPoorNot Sure
Cats?*

GoodFairPoorNot Sure
Children under 10 y/o?*

GoodFairPoorNot Sure
Strangers?*

GoodFairPoorNot Sure
Do you often have people visit your home?*
Please list at least 2 good qualities that the dog displays*
Please list at least 2 bad habits the dog displays*
Where does the dog sleep?*
With whom?*
Is the dog housebroken?*

YesNoSemi
How many hours can the dog be trusted to not "go" in the house if left alone?*
If male, is the dog marking indoors?

NoSemiYes
What are the dog's normal times for going outside?*
What word do you use to tell the dog to "do its business?"*
Does the dog have an aversion to wet grass, rain, snow etc. ?*
Describe daily exercise this dog gets and amount (i.e. two 15 minutes walks)*
Does the dog have any fear problems with thunder? Loud noises? Objects (sticks, brooms anything that would cause the dog to be fearful)*
Does your dog have any behavioral issues? (leash/barrier reactivity, resource guarding, etc.)*
Is the dog crate trained?*

YesNo
Baby gate trained?*

YesNo
X-pen trained?*

YesNo
Is the dog home alone by himself while you are at work or otherwise away?*

YesNo
How does the dog usually spend the day*

roams freecrateconfined to a certain area of the housegaragefree outdoor fencedchained outdoorsOther
Does/can the dog use stairs regularly?*

YesNoUnsureOther
What brand of dog food are you currently using?*
*

canneddrycombination
Approximate amounts per each meal (ex. 1 cup)*
Mealtimes*
Please list the dog's favorite chews and treats*
Does the dog tolerate baths?*

YesNoUnsure
Does the dog tolerate nail trims?*

YesNoUnsure
Any special grooming procedures?*
List of possessions transferred with pet*
Other information that helps us find the perfect home*
Please check these statements. These are REQUIRED for both returned dogs and surrendered dogs.
I certify that the dog described in this document that is being surrendered HAS NOT bitten any human or animal within the last 30 days.

YesNo
I certify that the dog described in this document that is being surrendered HAS bitten any human or animal within the last 30 days.

YesNo
If this dog HAS bitten a person in the last 30 days. Please elaborate the reason or the conditions under which this incident happened, WHEN the incident occurred and the extent of the bite wound.
Please check these statements. Note that if you do not check "yes" for all of the following, we may not be able to take your dog into our program.
I hereby declare that I am the legal owner of dog that is being surrendered and I am willingly surrendering the dog to CO Corgis and Friends Rescue, herein known as CCFR, and that I have indicated all information possible to ensure the continued happiness of this dog and understand that CCFR will do their best to place the dog in a loving and permanent home.*

YesNo
I understand that once this contract is signed, this dog becomes the legal property of CCFR and that I no longer have rights to this dog, that I am relinquishing my present and future rights to this dog, and that I may not request information or the new whereabouts of this dog once I relinquish ownership.*

YesNo
To the best of my knowledge I have divulged any and all behavior, physical or emotional issues to CCFR so they may seek a home for the dog's continued happiness and well-being. I will relinquish all material pertinent to this dog including veterinary history and any possessions that would benefit the dog in helping with a smooth transfer to its new home.*

YesNo
If the dog I am surrendering displays aggressive, reactive, or otherwise dangerous behavior to a human or animal that is not divulged in this agreement, I understand that CCFR has the right to take steps to rehabilitate this dog AT MY EXPENSE. This may include boarding, training, and/or humane behavioral euthanasia.*

YesNo
I HEREBY AGREE TO THE ABOVE AND SURRENDER ALL MY INTEREST IN THIS DOG TO CCFR AND ITS AGENT TO BE ADOPTED TO A NEW HOME AT THEIR DISCRETION.*

YesNo
Former Owner's Signature*
Date

MonthDayYear
Date
CCFR Representative
Please upload a couple recent photos of the pet you would like to surrender. If you have vet records, please send those as well.

Cancelof
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