Intake/Owner Surrender Form

Sometimes, unfortunate circumstances dictate the need to find a new home for our pets. We understand that giving up your pet is a difficult decision, but we realize that in making this choice, you are thinking about your dog’s best interests. When you are ready we are here to help.

Please provide as much information as possible. Above all, please be forethright and transparent; we understand your dog may not be perfect, but the more we know the better we are able to find the perfect new home for your dog.

If you need to speak with us, we are here to help. Call GRSF at 954-235-8211 or email GRSF@saltypawsh.com

Date*

Dog’s Name*

Owner Name*

Owners Address*

Street Address

CityState / Province

Postal / Zip Code

Phone*

Email Adress*

Breed*

Is your dog a pure bred golden retriever?*

yesno

Gender*

MaleFemale

Spayed/Neutered*

YesNo

Dog’s Birthday

Age*

Dogs Weight*

How long have you had your dog?*

Are you the first owner of this dog?*

If you are not the first owner of the dogs, please outline anything you know about the dogs life with prior owner. Why did they give the dog to you? If you are the first owner NA.*

Where did you get this dog? If from a shelter or rescue group, which group was it?*

Reason for surrender*

Is dog good with other dogs?*

YesNoUnknown

Is dog good with cats?*

YesNoUnknown

What other animals do you have in your home or animals the dog has been exposed to. and please share how the dog is with children. *

Is dog good with young children?*

YesNoUnknown

Is dog good with older children?*

YesNoUnknown

Do you have children in your home or has the dog been exposed to children? If yes, ages and please share how the dog is with children. *

Is dog house trained?*

YesNo

Is dog crate trained?*

YesNo

Does the dog have any behavior issues - please list as much detail as possible.*

Has your dog ever snarled, growled or bit a human? If yes, please describe?*

What commands does your dog know? Does your dog walk well on the leash?*

What are the dog's good points? What is your dogs personality?*

In what areas do you feel your dog could use some help or make improvements in their behavior?*

What brand(s) of dog food are you currently feeding your dog?*

Is dog microchipped?*

YesNo

Microchipped number (or enter NA)*

Date of last Vet visit:*

Date

Reason for visit:*

Medical/Vaccine records provided?*

YesNo

Name and Phone number of veterinarian/animal clinic:

Date of last Heartworm test

Date

Heartworm prevention given?*

YesNo

Product used or enter NA*

Date next dose due

Date

Flea protection given*

YesNo

Product used

Date next dose due

Date

Does your dog have health issue?*

YesNo

If yes Please explain

Is your dog on medication?*

YesNo

If yes please list meds

Does the dog need to be moved into our rescue immediately or are you able to keep the dog safe while we work to secure a foster and/or forever home? What is your timeframe in moving the dog from your home?*

Upload Photos - Photos and Videos are required to rehome your dog. You can also text or WhatsApp to 305-395-8881, in your text include the dogs name.

Upload any medical records or documents here

By my signature below and form submission, being the owner or the fully appointed agent of the dog described above, I hereby affirm that all the information contained in this form is true and correct to the best of my knowledge and belief.

I understand that Golden Rescue South Florida, “GRSF” will utilize the information provided to determine if my dog can be accepted into GRSF and GRSF will use the information to select a foster or adoptive home for my dog. I understand that I may be held liable for any and all claims, suits, damages, and fees related to or in any manner connected with this dog that is a result of false or misleading information provided on this form.

I understand if the dog is accepted into GRSF, once the dog has left my possession, I am surrendering the dog to GRSF of my own free will. I acknowledge that only once the dog leaves my possession, I relinquish all claims of ownership of the dog described. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, actions, damages, suits, or otherwise against Golden Rescue South Florida, Inc. their present and former agents, volunteers, employees, attorneys, accountants, affiliated companies, partners,
spouses, beneficiaries, heirs, executors, predecessors, successors, assigns with respect to this dog. I understand that the Golden Rescue South Florida, Inc. will not return the dog to me, once left in its care, under any circumstances, unless otherwise approved by the Golden Rescue South Florida, Inc. Board Director. I acknowledge and agree that I am qualified, authorized and have the capacity to execute this agreement and do so willingly and not under duress.

Owner Signature*

Date