Surrender Request Form
Please note that filling out this form is only to provide us with the information needed to determine if we can suitably place your pet in our rescue.
Owner Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Dog Information
Dog's Name
*
Breed
*
Gender
*
Male
Female
Age (Date of Birth of known)
*
Weight/Size of Dog
*
Small (under 30 pounds)
Medium (30-50 pounds)
Large (50-80 pounds)
X-Large (80+ pounds)
Exact weight, if known.
Physical description (color, coat length, slim, docked tail, etc)
How long have you had the dog?
*
Where did you get the dog from?
*
Reason for surrendering. Please be as detailed as possible.
*
Have you received any assistance for this reason. (eg; Vet, Trainer, Behaviouralist, etc)
*
Health and Medical Care
Is the dog spayed/neutered?
*
Yes
No
If no, please specify reason why.
If yes, tattoo or microchip number if known.
Is the dog up to date on current vaccinations?
*
Yes
No
If yes, please specify which types.
DHPP/Distemper
Rabies
Bordatella
Is the dog up to date on any other vetting needs?
Flea and Tick Prevention (ie; Bravecto, Nexgard, etc)
Heartworm Test
Heartworm Prevention (ie; Heartgard, Spectra)
Deworm
Please specify and explain any medical conditions that apply. (ie; Allergies, previous surgeries, current medications, Lyme Disease, Heartworm Disease, gastrointestinal issues, etc)
*
Home
Where is the dog kept when it is alone?
*
Kennel
Separate room
Loose in house
Outdoors
Other
If other, please specify
How long is the dog left alone without human companionship?
*
Where is the dog kept at night?
*
Kennel
Separate room
Loose in house
Outdoors
Other
If other, please specify.
Is the dog kept:
Mainly indoors
Mainly outdoors
If mainly outdoors, or other option please specify.
Indicate all ages and number of adults and children in current home:
*
Indicate all species, breed, gender and age of all pets in current home:
*
What is the current home like? (ie; time spent alone, time spent with people, exercise, meal times, play time, etc) Please be as detailed as possible.
*
What would the most suitable home be like? (ie; time spent alone, time spent with people, exercise, meal times, play time, etc) Please be as detailed as possible.
*
Personality and Behavior
Please describe how the dog interacts with cats and other small animals. (in the home, outside the home, in new environments, cats coming into the home, etc.)
*
Please describe how the dog interacts with other dogs. (in the home, outside the home, in new environments, dogs coming into the home, etc.)
*
Please describe how the dog interacts with children and adults. (in the home, outside the home, in new environments, children and adults coming into the home, etc)
*
What is the dog's energy level?
*
Low
Moderate
High
Very High
Please explain.
*
Is the dog house trained?
*
Yes
No
Is the dog kennel trained?
*
Yes
No
Does the dog guard toys, food, people, spaces?
*
Yes
No
Please explain.
How does the dog do on walks/on leash? (pulls, sometimes pulls, never pulls, barks at passing people or dogs, fearful, etc.)
*
Has the dog ever bitten? (a person, another dog, another animal)
*
Yes
No
Please explain.
Does the dog show any of the following behaviors?
*
Growling
Barking
Snapping
Cowering
Hiding
Excessive licking/grooming
Jumping up (on people, counters, etc)
Excessive whining
Destructive chewing (furniture, personal belongings, doors, kennel, etc)
Other
Please explain.
*
Current Veterinarian
We will require this information to access medical records and history if the dog is brought into rescue. Please note you will need to give your vet clinic permission to release this information to us before we can complete the surrender.
Vet Clinic/Veterinarian name:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please upload a picture of pictures of the dog
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Please upload any other qualifying files or records you would like to share.
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By submitting this form electronically, I acknowledge that the above information is correct, and I understand that the information will be verified if needed. I acknowledge that I understand this form does not finalize the surrender of my dog, and that the rescue will only complete the surrender if they have suitable space available. I am under no obligation to relinquish my dog to Funds for Furry Friends after completion of this form, nor is Funds for Furry Friends under any obligation to accept my dog into rescue. Please note that if Funds for Furry Friends takes in your dog you are required to provide vetting records and paperwork if applicable, before the completion of the surrender.
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