Animal Surrender/Intake Request

Rustic Rover Rescue & Lodge Inc.
Dog Surrender/Intake Request
If you need to rehome your dog, we accept dogs that are up to date on vaccinations, good with other dogs and humans . If your dog fits that criteria, please fill in and submit this form and follow the instructions at the bottom for sending us photographs.
Your "Owner" Full Name*
Your Email*
Your Phone*
Do you text?

YesNo
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Animal's Name*
Full Blooded/Perdigee

YesNo
Breed 1 :If a mix breed please list the top two breeds. If you have an DNA please provide*
Breed 2 :
Color(s)*
Age*

Under 8 weeks8 weeks to 4 months4 months to 1 year1-3 years3-6 years6-9 years9+ years
Microchip#/Brand
Approximate Weight*

15 lb or less16-30 lb30-45 lbOver 45 lb
Socialization*

Sweet and socialA little shy but warms up when you're niceVery shyDefinitely abusedFear biter
Has your dog had any vaccinations, heartworm testing, has it been altered (spayed or neutered)? If not, please explain the reason.Proof of vaccinations, etc. will be required before an intake date can be scheduled and a negative test result at time of surrender, is highly recommended*
What is your reason for surrender? *
Where did you orginally acquired your pet from and when?
Please descript what you believe would be the prefect home for your pet? Example: Family with kids, For Adults Only, A One-Person dog. Someone that works from home? accidents indoors? crate trained? Length of hours is ok he/she can be left alone ? What other animals has he/she lived with in the past and how did they do?*
How did learn of Rustic Rover Rescue?
Behavior , Please check if your pet exist the following behavior issues?

BarksChews Personal ItemsScratches on doors/windows/floors/etc.Defecates indoors/marks/urinatesAfraid of strangers/kids/men/hatsFearful of vet appointments, storms, being left aloneScared of loud noises, car ridesOther
Amount of donation offered to help us cover the cost of vetting/caring for this dog?
When we take a dog in, we keep it in our home with our family and pets. Whether it takes weeks or months to find it a home, we keep the dog with us and incur the cost of it's care and vetting. We do not received grants. We are funded soley by donations, boarding and adoption fees. A donation is always appreciated when relinquishing your pet into the program.

Also, Providing personal items such as a crate, bedding, food, toys can also help
your pet transition into the program.
What commands do your dog know?

sitstop/holt/nocome/recalldown or offHeelwait/hold/stayOther
Other helpful information about my pet:
Please take 3 good quality, well lit photographs of the animal and email them to us at rusticrover@icloud.com with your name and the animal's name in the subject of the email. If you have any videos of the dog, please send us the links to them on youtube.

Pictures should be of the dog's face, side and if possible one showing his/her tail.
Please review and sign below acknowledging the following:
• The above information reflects the animal in which I am surrendering to Rustic Rover Rescue & Lodge, Inc
• I am the owner of this animal and have full right to surrender him/her.
• I understand that I this animal is will be under the complete ownership of Rustic Rover Rescue & Lodge, Inc. once the animal is accepted into the program.
• My signature below reflects that I have read and understand the information provided above and I am hereby releasing all rights for this animal to Rustic Rover Rescue & Lodge. Inc.
I also hereby certify that the animal has NOT bitten or scratched a human or another animal within the past 10 days. I understand that once I relinquish the animal, the animal may not be available to be returned. I further certify that I have read and understand the terms of this Animal Surrender Form.
Should be Empty:

Rustic Rover Rescue & Lodge Inc.

Dog Surrender/Intake Request