Mutts & Misfits Dog Surrender Form

Dog Surrender Application

Please thoroughly fill out this form to help us find the safest and most appropriate home for the dog being re-homed. Undesirable behaviors and/or medical issues do not necessarily create issues placing the dog in a new home, however NOT disclosing behavioral issues, medical history, or any history of behavioral issues does. Full disclosure of the animal's history & displayed behaviors is vital to helping us set the dog up for success in a new home that will be a good fit.
Current Legal Owner of Dog*

First NameLast Name
Your Name*

First NameLast Name
Phone*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOG & HOUSEHOLD INFORMATION
Dogs Name*
When did you acquire the dog & what age was the dog?*
How long have you had the dog?*
What is your reason for surrender? *
Sex*

Unaltered MaleUnaltered FemaleAltered MaleAltered Female
Age/Birthdate*
What is the dogs breed/breed mix?*
How did you acquire the dog?*

BreederRescue/shelterRe-homedFoundBorn in my homeOther
Is the dog microchipped?*

YesNoUnsure
If the dog is microchipped, please provide brand & number:

Including yourself, how many people of the following ages live in your home?*

Rows	FEMALE	MALE
00 - 03
04 - 09
10 - 17
18 - 29
30 - 59
60 +

What other animals did the dog live with?*

no other animalsdogscatsOther
If any, please list all other household pets, including age/sex/species.
BEHAVIOR

Your dogs usual behavior

How does the dog usually behave towards people they know?*

Rows	never encounter	friendly	afraid	show teeth/growl	snaps	bites	other
men
women
children

How does the dog usually behave towards people they DO NOT know?*

Rows	never encounter	friendly	afraid	show teeth/growl	snaps	bites	other
men
women
children

How does the dog usually behave towards animals they know?*

Rows	never encounter	friendly	afraid	show teeth/growl	snaps	bites	other
dogs
cats

How does the dog usually behave towards animals they DO NOT know?*

Rows	never encounter	friendly	afraid	show teeth/growl	snaps	bites	other
dogs
cats

Comments on answers above
How does the dog usually react when an unfamiliar person approaches or enters the yard or house?*

friendlyafraidbarksshows teeth/growlswill bite
How is the dog normally confined to your property when outside*

Fenced YardTied Up (chain/rope)Kennel or EnclosureElectronic Pet ContainmentDog HouseOther
Has this dog ever escaped its confinement?*

yesnopartially
If yes to the above, please elaborate
Is the dog house trained?*

yesnopartially
Where does the dog spend the majority of their time?*

inside the house, runs freeinside the house, cratedoutside the house, runs free in yardoutside the house, kenneloutside the house, tied upOther
How many hours a day is the dog left alone without a human?*

never1-3 hours4-8 hours9-12 hoursover 12 hours
When left alone, is he/she...*

outdoorsfree roam in homeconfined to a roomcratedOther
When left alone, does the dog usually show any of the following behaviors?*

destroy household itemsurinate/defecatebarkcrynone of theseOther
What toys does the dog like?*

ballsfrisbeeplushsqueakytug toynoneOther
What games does the dog like?*

fetchtugchasewrestlingnoneOther
Is the dog scared of anything*

yesno
If yes, please explain
Please tell us the dog's bad habits*
Is the dog allowed on furniture?*

yesno
Where does the dog usually sleep at overnight?*

crateflooryour bedcouchkids beddog bedoutsideOther
What commands does the dog know?*

no commands knownsitdownstaycomeleave itplaceheelOther
Describe the dog's leash skills*
Describe the dog's reaction if a person or other dog gets near or attempts to take food he is eating.*
Describe the dog's reaction if a person or other dog attempts to take a toy they are playing with.*
Does the dog have problems riding in car?*

yesnodon't know
If yes, please explain
Has the dog escaped your property 1 or more times in the last 6 months?*

yesno
If yes, please explain
BEHAVIOR

(behavior that has ever happened)
Has the dog ever attacked or bit a person?*

yesno
If yes, please explain
Has the dog ever attacked or bit another dog?*

yesno
If yes, please explain
Has the dog ever attacked or bit a cat?*

yesno
If yes, please explain
Has the dog ever attacked or bit farm animals? (chickens, horses, cows, goat, pig, sheep, etc...)*

yesno
If yes, please explain
Please CHECK ALL that apply to the dog ...

Has attended doggy daycareGoes to the Dog ParkWalks on a leashHas formal trainingDisplays separation anxietyHas bitten somebodyHas been in an altercation with another dogProne to eating foreign objetsProne to diggingLikes to try and escape
MEDICAL
Please list all veterinarians that have seen the dog, including address and number.*
Does the dog see a veterinarian at least once a year?*

YesNoUnsure
Is the dog spayed/neutered?*

YesNoUnsure
What vaccinations has the dog recieved?*

RabiesDHPPBordetellaNoneLeptospirosis
Are vaccinations current?*

YesNoUnsure
Has the dog been tested for heartworm?*

YesNoUnsure
If yes, what were test results
Is the dog taking heartworm preventative?*

YesNoUnsure
If yes, when is the next dosage due?

Check if the dog has ever shown any of the following behaviors when handled by a vet or groomer.*

Rows	never done	shows teeth/growls	snap	bite	none of these
examine
restrain
administer shots
bathe
clean ears
trim nails
take blood

Does the dog have to be muzzled at the veterinarians?*

yesno
Does the dog have any past or present health problems?*

yesno
If yes, please describe
Is the dog currently taking any medication?*

yesno
If yes, please list medications
FEEDING
What type of food does the dog eat?*

canneddrysofttable scrapsrawhome cooked
What brand of food is your dog on?
How many times a day is the dog fed?*

1 time2 times3 timesfree feeds
How much is fed per feeding?*

1 cup1 1/2 cup2 cups2 1/2 cupsnot sure, just fill the bowl upOther
OTHER
Please feel free to tell us any other information about the dog you feel is important.
Please upload a full body picture of the dog*

Cancelof
Please upload a up close head shot of the dog*

Cancelof
Please upload any records you have for the dog

Cancelof
DOG SURRENDER
I, blanks* , agree that myself, my spouse and/or any co-owner of the dog described in this form are irrevocably transferring and relinquishing to Mutts & Misfits Dog Rescue legal ownership of said dog on the date of surrender/acceptance. This gives Mutts & Misfits Rescue complete authority to take whatever actions are necessary and in the best interest of the dog.
Signature*
Should be Empty:

Dog Surrender Application

DOG & HOUSEHOLD INFORMATION

BEHAVIOR

BEHAVIOR

MEDICAL

FEEDING

OTHER

DOG SURRENDER