Owner Surrender Form

We understand that giving up your pet may be a difficult decision, but we realize that in making this choice, you are thinking more about your dog's best interests. We are here to help. Please provide as much information as possible. Above all, please be honest; we understand your dog may not be perfect, but the more we know then the better we are able to find the perfect new home for your dog. Your dog deserves a second chance to find a wonderful home, and by providing us with the most detailed information, you will help Carol's Senior Pet Sanctuary better accomplish this goal. All questions should be answered - if not applicable or you don't know, please enter N/A. Thank you for trusting Carol's Senior Pet Sanctuary with your dog's future.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Best time to call

Email

example@example.com

By what date must you surrender the dog?

Are you the sole legal owner of the dog?

YesNo

Dog's name, age, sex, color, weight

Additional information

Where did you get this dog and how long have you had him/her?

Do you have AKC papers?

YesNo

Is the pedigree available?

YesNo

Is the dog microchipped? If microchipped, what is the number?

Are vaccinations current?

YesNoUnknown

If yes, which vaccinations are current?

DHPPRabiesBordetella

Is dog on heartworm preventative? If yes, what type of preventative?

When was last heartworm preventative given?

When was last flea/tick preventative given?

Has the dog ever had a seizure? If yes, how often does he/she have seizures?

Does the dog have an ear problem/recurring infections?

YesNoUnknown

Does the dog have any orthopedic problems (Hip dysplasia, arthritis, stiffness)? If yes, what sort of problems?

Does he/she have any skin problems? If yes, what sort of problems?

Does the dog have any allergies? If yes, what sort of allergies?

Does he/she have any other medical conditions? If yes, what conditions?

I understand that Carol's Senior Pet Sanctuary will make every effort to find a loving home for my dog and grant my permission to contact the medical service provider named below and hereby grant permission for the release of all record and information in their possessions. If is the owner's responsibility to ensure that Carol's Senior Pet Sanctuary has a copy of the dog's records prior to, or at the time of, the physical surrender. Please note that Carol's Senior Pet Sanctuary will not take possession of the dog unless vet records are provided.

Veterinarian's name

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is the dog's disposition?

Is the dog confident or shy?

ConfidentShy

Can you take food away?

YesNoUnknown

Can you take toys away?

YesNoUnknown

Can you take bones away?

YesNoUnknown

Does the dog dig?

YesNoUnknown

Does the dog chew?

YesNoUnknown

Does the dog escape from the yard or house?

YesNoUnknown

Does the dog run away?

YesNoUnknown

Does the dog jump over or climb fences?

YesNoUnknown

Does the dog jump on people?

YesNoUnknown

Does the dog steal food or items from the counters or tables?

YesNoUnknown

Does the dog swim?

YesNoUnknown

Does the dog ride well in cars?

YesNoUnknown

Is this an inside outside dog?

InsideOutside

Is this dog housebroken?

YesNoUnknown

Is this dog crate trained?

YesNoUnknown

Does the dog get along with other dogs?

YesNoUnknown

Does the dog get along with cats?

YesNoUnknown

Does the dog get along with other animals?

YesNoUnknown

Is this dog aggressive to other dogs? If yes, what did the dog do to make you think it didn't like the other dog?

Is this dog possessive over the food dish?

YesNoUnknown

Does the dog accept men?

YesNoUnknown

Does the dog accept women?

YesNoUnknown

Does the dog like to chase bikes or cars?

YesNoUnknown

Does the dog get along with children?

YesNoUnknown

Has the dog ever lived with children? If yes, for how long and what are the children's ages?

How did the children treat the dog?

Is there anywhere the dog does not like to be touched?

Is the dog afraid of thunderstorms? If yes, what does this dog do during a thunderstorm?

Has the dog ever growled at a person? If yes, please describe the circumstances.

Has the dog ever snapped at a person? If yes, please describe the circumstances.

Has the dog ever bitten a person? If yes, please describe the circumstances.

Has the dog ever growled at or bitten another animal such as a dog or a cat? If yes, please describe the circumstances.

Has the dog ever displayed any other signs of aggression? If yes, please describe.

Does the dog like to grab your arm or clothes (mouthy)? If yes, please explain.

What does the dog dislike

What is the dog afraid of?

Has the dog been to obedience school? If yes, which obedience school?

Does the dog know any commands? Please list:

Please describe your training methods.

Have you ever disciplined this dog when he/she has done something wrong? Please describe.

Has the dog ever lived with other dogs?

YesNoUnknown

Has the dog ever lived with cats?

YesNoUnknown

Is this dog used to being home alone during the day? If yes, how many hours on average?

Does the dog have separation anxiety? If yes, how do you handle it?

How do you exercise the dog? How often?

What type of food is the dog eating now?

How often is he/she fed? At what time(s)?

Is the dog on any vitamins or supplements? If yes, please list.

Why are you giving up this dog? Please be as detailed as possible.

What are the dog's bad points? Please be as honest as possible - we know he/she may not be perfect but the more we know about him/her, the better we are able to select a suitable foster home and then the very best permanent home for him/her.

What are the dog's good points? Again, the more we know about him/her the easier it is find the perfect home for him/her.

Is there anything else that you would like us to know about the dog?

The undersigned, being the owner or the fully appointed agent of the dog described below and in the accompanying Owner Surrender Form, does hereby affirm, acknowledge and warrant and represent that all information contained in this profile is true and correct to the best of their knowledge and belief.

I understand that Carol’s Senior Pet Sanctuary will utilize the information contained in this form to assist in selecting an appropriate Foster Home and Adoptive Home. I understand that I may be held liable for any and all claims, suits, damages, liabilities and costs (including reasonable attorney fees) related to or in any manner connected with this dog that is a result of any false, untrue or misleading information provided in this form that therefore results in the dog being placed in an inappropriate home, situation or environment.

Please review the form, to ensure you have been as thorough as possible. Once the form is submitted a volunteer will contact you to discuss any questions you may have about our process, or that we may have about your dog.

We ask for your patience; we will contact you within 24 hours. Please note that summer months and holiday periods are our busiest times.

Please note that we do not buy or pay for dogs. This is a service to help place your pet in a wonderful new home that has been thoroughly vetted, and that will be monitored for the duration of the dog’s life. A donation to help pay for expenses is appreciated.

We ask that you bring copies of all veterinary records and any other necessary paperwork at the time you release the dog into our care. If you are able, including any of the dog’s favorite toys or bedding will help ease the transition to his/her foster home.

To expedite the process, please e-mail photos of your dog to carolspetgroomingsalon@gmail.com. Please include the dog’s name in the subject line and your name in the body of the e-mail.

At the time of actual physical surrender of the dog, you will be required to sign the above Owner Surrender Form and the attached Owner’s Surrender Agreement releasing the dog to Carol’s Senior Pet Sanctuary. Please understand that Carol’s Senior Pet Sanctuary will take full and complete ownership of the dog immediately following the physical surrender and that you will not be permitted to see or visit it at any future date, unless the adoptive home should be amenable to such an arrangement; Carol’s Senior Pet Sanctuary would pass on a request to allow you to visit but will make no guarantees that this will be approved, nor will we accept a dog with the stipulation that future visits be permitted. You may contact Carol’s Senior Pet Sanctuary periodically to inquire as to the dog’s wellbeing, but you will not be informed of the dog’s whereabouts or provided with any identifying details regarding the dog’s foster or adoptive home.

Today's Date

Owner Surrender Form

Dog Information

Medical Summary

Veterinarian Information

Behavior Assessment

Home Environment

Additional Comments