Dog Owner Surrender Form

1
If you are having a behavior or financial problem with your dog, would you consider keeping him/her if we could help you with training, pet food, pet supplies, medical care and other pet items?
YESNO
2
Your Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Dog's Name* This field is required.
7
Reason for surrenderThere is no judgement, please be completely honest with us
Please Select
Please Select
Financial hardship
Not enough time
Housing
Aggression issues
Medical needs of pet
Other
8
Reason for surrender - please provide more information* This field is required.There is no judgement, please be completely honest with us
9
Breed* This field is required.please provide best guess
10
Age* This field is required.please provide best guess
Please Select
Please Select
Less than 6 months
6 months - 2 years
2 - 6 years
6 - 10 years
10 years +
11
Male or Female* This field is required.
Male
Female
12
Spayed/Neutered* This field is required.
Yes
No
I'm not sure
13
Are you this dogs first owner?* This field is required.
YESNO
14
How long have you owned this dog?* This field is required.
15
Where did you get this dog from?* This field is required.
Breeder
Pet Store
Animal Shelter
Family/Friend
Found on street
Newspaper/internet ad
16
If you selected this dog was from an animal shelter, were they adopted from our organization?This helps us find a matching adoption in our system quicker, if applicable. This is NOT a required question. Hit "NEXT" if not applicable.
Yes
Yes, but the adoption may be under another person's information.
No
No, and I have contacted the other shelter and they cannot take my dog back.
No, and I have not contacted the shelter they were adopted from.
17
Approximately, how much does this dog weigh?
less than 15 pounds
16-30 pounds
30 or more pounds
18
Has your dog ever bitten a PERSON?* This field is required.
YESNO
19
When did the bite occur?This is NOT a required question. Hit "NEXT" if not applicable.
Date
Year
Month
Day
20
If your dog has bitten a PERSON, did that person require medical attention?This is NOT a required question. Hit "NEXT" if not applicable.
YESNO
21
Who did the dog bite?This is NOT a required question. Hit "NEXT" if not applicable.
Child
Adult
Stranger
Someone the dog knew
N/A
22
Please describe the bite incidentThis is NOT a required question. Hit "NEXT" if not applicable.
Huge
Large
Normal
Small
Ok
Ok
23
Has your dog ever ATTACKED another animal?* This field is required.
YESNO
24
When did the ANIMAL ATTACK occur?This is NOT a required question. Hit "NEXT" if not applicable.
Date
Year
Month
Day
25
Was veterinary medical attention required for the victim animal?This is NOT a required question. Hit "NEXT" if not applicable.
YESNO
26
Please describe the animal ATTACK incident(For example, a stray cat walked into yard, dog saw cat and chased it and attacked it.) This is NOT a required question. Hit "NEXT" if not applicable.
Huge
Large
Normal
Small
Ok
Ok
27
Do you have to keep this dog away from strangers due to aggressive behavior?* This field is required.(For example, growls/snarls, lunges, tries to bite)
YESNO
28
How does the dog react to being approached by strangers?* This field is required.(For example, on a walk and stranger approaches, what does the dog do?)
29
What human age groups has your dog lived with? Please check all that apply* This field is required.
under 5 years old
5 - 12 years old
12 - 18 years old
18 years old +
30
How does this dog interact with other dogs?* This field is required.
Playful
Shy
Aggressive
unknown
31
How does this dog interact with cats?* This field is required.
Playful
Shy
Aggressive
unknown
32
Is your dog housebroken?* This field is required.Select no if still has accidents
YESNO
33
Is your dog crate trained?* This field is required.
YESNO
34
When you are away from home, the dog is* This field is required.
In a crate
Restricted to one room of the house
Loose in the home
In an outdoor kennel
On a tie-out in the yard
Loose in a fence in yard
35
Does your dog know any commands?* This field is required.
Sit
Down
Come
Leave it
Beg
Roll Over
Kennel/Crate
Shake/Paw
Speak
Off
Stay
Go Potty/Go Poop/Go to the Bathroom
None
36
Is this dog sensitive to touch?* This field is required.
YESNO
37
Is this dog possessive of food or toys?* This field is required.For example, you approach dog while eating or playing with toys and he/she growls/shows teeth/lunges
YESNO
38
If you selected yes, that your dog is possessive of food/toys, who is this displayed towards?Please select all that apply. This is NOT a required question. Hit "NEXT" if not applicable.
All people
Only unfamiliar or non-family members
Other animals
39
If you selected yes, that your dog is possessive of food/toys, in which of these situations your dog guard?Please select all that apply. This is NOT a required question. Hit "NEXT" if not applicable.
When approached while eating
When taking food away
When approached while chewing on a high value item (raw hide, bone, etc.)
When taking away a high value item
When approached while playing with or chewing on a toy
When approached by someone while getting attention from their favorite person
When approached while in their "safe space" (bed, crate, home, yard, etc.)
When approached after stealing something they shouldn't have
40
If you selected yes, that your dog is possessive of food or toys, what do they do?Please select all that apply. This is NOT a required question. Hit "NEXT" if not applicable.
May growl, but allows item to be taken away with no issue
Growl, cannot take items away safely
Show teeth/lifts lip
Get stiff (body freezes, hair raises on back, tail erect)
Snap/Lunge to try and bite
41
If you marked that your dog is possessive of food or toys, what do they do?
Huge
Large
Normal
Small
Ok
Ok
42
Choose any that fit your dog:* This field is required.
Jumps fences
Tears up carpet/furniture
Barks/howls (incessantly)
Gets into the trash
Rides well in cars
Digs
Chews shoes/personal objects
None of the above
43
Can the dog be left alone in a fenced yard?* This field is required.
YESNO
44
Is your dog prescribed any medications or taking any supplements? * This field is required.If no, please type 'NO'
Huge
Large
Normal
Small
Ok
Ok
45
Has your dog had any of the following medical conditions in the past or currently?* This field is required.
Allergies
Arthritis
Blindness
Cancer
Deafness
Ear Infections
Heart Disease
Heartworms
Thyroid Issues
Parasites (worms)
Kidney Disease
Parvo
Urinary Stones
None
46
Has your dog had any surgeries other than spay/neuter?* This field is required.If no, please type 'NO'
Huge
Large
Normal
Small
Ok
Ok
47
Are vet records available for your dog? If yes, please provide Vet information* This field is required.If no, please type 'NO'
Huge
Large
Normal
Small
Ok
Ok
48
Please upload a current photo of the dog* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
49
What have you done to re-home this dog? Why did it not work?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
50
Signature* This field is required.READ BEFORE YOU SIGN!: As owner, or concern citizen acting in good faith, if approved for surrender, I give the described animal(s) listed below irrevocably to the South Suburban Humane Society for possible adoption, transfer to another organization, or humane euthanasia at its discretion. Once surrendered to the South Suburban Humane Society, information regarding the treatment or outcome of the described animal(s) below will NOT be available to the surrendering party.
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