Animal Surrender/Intake Request-MLdraft

Dog Surrender/Intake Request
To surrender a dog, please complete the following Hard Licker Ranch Surrender Form. Hard Licker Ranch will NOT consider accepting a dog until a surrender form has been completed.

IF YOU ARE SURRENDERING MULTIPLE DOGS, PLEASE COMPLETE A SURRENDER FORM FOR EACH DOG.

The surrender form allows us to have a better idea of why the dog is being surrendered, any behavior issues, health issues, etc. Hard Licker Ranch cannot consider placing a dog if we do not have a complete temperament and medical background. It is critical that you complete the application as all of our foster homes have other pets and/or children and we consider their safety first. Because surrendered dogs are placed in foster homes with other pets and/or children, we cannot accept dogs that are aggressive and/or have a bite history (provoked or not).

Completion of this form does not guarantee that Hard Licker Ranch will accept your surrendered dog. Because of foster home or fund limitations, it is sometimes necessary to place the dog on a waiting list. Upon receiving the application, we will consider your dog for our program and look for a suitable foster home; we will contact you about the status of the surrender.

Be Advised: At the time of the surrender, Hard Licker Ranch reserves the right to revoke acceptance of a due due to aggression, lack of medical records, misrepresentation, etc. Please understand that we are an all-volunteer organization and that it may take up to 48 hours to get back to you regarding your inquiry.

In addition, once we decide to take a dog in it takes time to find a foster home and arrange transport; we will not be able to drop everything and accept your dog. Typically it is not an extremely quick process so be prepared for a wait period before we can accept your dog.
Your Name*
Your Email*
Your Phone*
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Animal's Name*
Breed*
Color(s)*
Age*

Under 8 weeks8 weeks to 4 months4 months to 1 year1-3 years3-6 years6-9 years9+ years
Approximate Weight*

15 lb or less16-30 lb30-45 lbOver 45 lb
Is the dog spayed/neutered?*

YesNo
Is the dog hearing and/or vision impaired?*

YesNo
What is your reason for surrender?
Environment
Has this been the dog’s only home?

YesNo
If no, why did the previous owners give up the dog?
Is the dog crate trained?

YesNo
Does the dog potty in the crate?

YesNo
Is the dog house trained?

YesNo
Where is the dog normally kept?

Free in houseFenced-in backyard/dog run/kennelCrateOne room/level of the houseChained outsideGarageOther
If other arrangements when you are home, please explain:
Where is the dog kept when you are not home?

Free in houseFenced-in backyard/dog run/kennelCrateOne room/level of the houseChained outsideOther
If other arrangements when you are not home, please explain:
Where does the dog sleep at night?

Dog BedCrateFloorPerson's BedOutsideOther room in the houseOther
If other sleeping arrangements, please explain:
Is the dog allowed on furniture

YesNo
Feeding
What brand of food is the dog eating?
How many cups does the dog get at EACH feeding?
At what times is the dog normally fed?
Does the dog have any food/treat allergies?

YesNo
If yes, please explain the food/treat allergies.
Behavior/Personality
Has the dog been to any type of obedience training?

YesNo
Please list all the commands/signals the dog knows.
Is the dog good with children?

YesNoUnsure - never been around children
If yes, please list the ages of the children the dog has been around.
Is the dog afraid of any of the following? (check all that apply)

FireworkdsStormsLoud NoisesWomenMenChildrenVacuum CleanersOther
Is the dog good with the following? (Please select all that the dog is good around/seeing on the street/yard)

MenWomenMale DogsFemale DogsLarge DogsSmall DogsCatsFarm AnimalsSquirrels/Small Outdoor AnimalsOther
Is the dog destructive?

YesNo
Has the dog ever bitten or snapped at anyone?

YesNo
Has the dog bitten or killed another animal? (including squirrels, rabbits, cats, dogs, chickens, etc.)

YesNo
If yes, please explain.
Does the dog do any of the following? (check all that apply)

Dig in the yardJump fencesChew/destroy items or furniture when aloneEat trashCounter surfJump on visitorsBark excessively for no reasonEscape from crate
What is the dogs temperament? (check all that apply - explain selections with * below)

ShyFearful*ExcitableAggressive*SubmissiveFeral*Demanding/NeedyNervous*AnxiousLaid backDominant*IndifferentOther
Please explain*
Does the dog live with other animals?

YesNo
If yes, please list all other animals in the home, their sex and age:
Does the dog ride good in cars?

YesNo
Does the dog like toys?

YesNo
Is the dog trained to walk on a leach?

YesNo
Does the dog resist grooming/nail trimming?

YesNo
Is the dog accepting of strangers?

YesNo
Please describe any other unusual behaviors not covered above:
Current Veterinarian/Clinic
Does the dog have a current Veterinarian/Clinic?

Yes (complete the below section)No (go to the next section)
Current Veterinarian/Clinic
Current Veterinarian/Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Veterinarian/Clinic Phone

Area CodePhone Number
Vaccinations
Select All Vaccinations the dog has received in the past year.

RabiesBordatellaDHPP or DHLPPN/A
Is the dog currently heartworm preventative?

YesNo
Date of last heartworm treatment (pill or shot)
Date of last heartworm blood test
What was the result of the heartworm test?

PositiveNegativeN/A
If positive, did the dog undergo treatment?

YesNo
Has the dog had any surgeries besides being spayed/neutered?

YesNo
If yes, explain the surgery and date of surgery.
Does the dog have any known medical issues or known allergies?

YesNo
If yes, please explain the allergies and treatment:
Has the dog been bred?

YesNoUnsure
If yes, how many times has the dog been bred?
Breeder
Did you receive your dog from a breeder?

YesNo
If no, where did you get the dog?
If yes, Please provide the Breeder’s Name/Kennel’s Name.
Breeder's Website
Breeder's E-mail
Breeder's Phone

Area CodePhone Number
Do you have contact with the breeder?

YesNo
Have you contacted the breeder about taking the dog back?

YesNo
If yes, what was the breeder's response?
Other Information
Is there any other helpful information we should know about the dog being surrendered?
Donation
When we take a dog in, we keep it in our home with our family and pets as well as in our temperature control barns. Whether it takes weeks or months to find it a home, we keep the dog with us and incur the cost of it's care and vetting. We rely on donations and are not funded through the city or state. We pay for our rescue work out of our own pockets. It is partially funded by our adoption fees, but does not come close to covering all of our expenses during the year.
Amount of donation offered to help us cover the cost of vetting/caring for this dog?
Photos
Please take 3 good quality, well lit photographs of the animal and email them to us at with your name and the animal's name in the subject of the email. If you have any videos of the dog, please send us the links to them on youtube.

Email: Hardlickerranch@outlook.com
Releases
By checking the Medical Release box and signing below, I certify that the information I am about to provide is true and correct. Additionally, I agree to call my veterinary clinic and give permission for the release of my pet’s medical records to a representative of Hard Licker Ranch.

By checking the Release of Pet Ownership box and signing below, I hereby transfer full ownership, right and responsibility of the dog to Hard Licker Ranch. I understand that after this date I shall have no interest or right to the dog and all decisions regarding the dog shall be made at Hard Licker Ranch's sole discretion. I further understand that I am not eligible to adopt the surrendered dog back from Hard Licker Ranch.

By checking the Liability Release & Waiver box and signing below, I accept this waiver and release Hard Licker Ranch from any and all liability. I am certifying that all the answers I have given are the truth. I also understand that this information might be shared with another rescue group if they call Hard Licker Ranch to inquire about the listed applicant(s).
I AGREE TO THE MEDICAL RELEASE (ABOVE)I AGREE TO THE RELEASE OF PET OWNERSHIP (ABOVE)I AGREE TO THE LIABILITY RELEASE & WAIVER (ABOVE)
To the best of my knowledge, the information I provided accurate and truthful

YesNo
Today's Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Dog Surrender/Intake Request

Environment

Feeding

Behavior/Personality

Current Veterinarian/Clinic

Vaccinations

Breeder

Other Information

Donation

Photos

Releases