Surrender Application

Cavalier King Charles Spaniel Rescue (Qld) Inc.

Registered as a charity with the Australian Charities and Not-for-profits Commission ABN 28 709 153 342
Surrender Application
phone: 0458 550 878

email: admin@cavalierrescue.com.au
Surrender
Name of Dog*
Surrender Date

MonthDayYear
Date
Age/DOB of Dog*
Sex*

MaleFemale
Microchip Number
Desexed*

YesNo
Local Council*
Council Registration Number
Weight kg
Weight*

Healthy weightUnder weightOver weight
Current Diet (including brands)*
Allergies to food or other irritants
Vaccination/s*

C3C4C5
Vaccination Due Dates *If relevant
Worming*

HeartwormAll-wormerUnsure
Worming Due Dates
Worming Products Used
Flea & Tick
Eye Health*

No issuesDry eyeWeepingConjunctivitisOther
If you've selected other, or there are any eye issues, please provide further information including treatment or further considerations below.
Ear Health*

Clean and odour freeDirtySmellyPossible infectionOther
If you've selected other, or there are any ear health issues, please provide further information including treatment or further considerations below.
Teeth / Dental Health*

No issuesHealthy pink gumsSome plaque/tartarRed or inflamed gums
If there are any teeth/dental health issues please provide further information including treatment or further considerations below.
Heart Health:*

No issuesSome concernUnsureDX murmur
If you selected DX murmur, please specify the grade.

IIIIIIIVVVI
If there are any heart health issues please provide further information including treatment or further considerations below.
Patella Health:*

No issuesSome concernUnsureDX Patella Luxation
If you selected DX Patella luxation please specify the grade.

IIIIIIIV
If there are any patella health issues please provide further information including treatment or further considerations below.
Skin Health:*

Healthy / appears goodDry / flakyRedItchyUnsure
If there are any skin health issues please provide further information including treatment or further considerations below.
Anal Gland Health:*

No issuesRecently expressedNeeds regular check & expressUnsure
Requires anal glad check*

YesNo
If scooting, how frequently?

SometimesFrequently
If there are any anal glad health issues please provide further information including treatment or further considerations below.
Medical History*

Previous surgeriesFracturesLigament repairsPancreatitisTick toxicityToad toxicityOther
If you selected any of the above, please provide further details.
Grooming & Hygiene
Coat*

GoodDryNeeds clip
Nail length*

GoodNeeds trim
Cleanliness*

GoodNeeds bath
Please provide any further details about Grooming & Hygiene including treatments or considerations.
Temperament & Behaviour
Level of training*

Obedience - BasicObedience - AdvancedNeeds trainingLittle-no trainingWalks wellPulls on lead
General Temperament*

ConfidentSocial/friendlyPlays with toysTimid / shySeparation distressBarks unnecessarilyOther
If you selected other, or there are issues with temperament, please provide further explanation.
Toilet Trained*

YesNo
Crate Trained*

YesNo
Usual Exercise*

Walks - slowWalks - mediumWalks - fast / long
Where does dog usually sleep? Used to being mostly indoors / outdoors?*
Reason for surrender*

Change in financial circumstancesResidential circumstancesFamily changes / new babyAllergies (family member)Behavioural IssuesOther
If you've selected behavioural issues or other, please provide further explanation below.
Owner's Declaration
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile phone*
Home phone*
I am the current owner of the dog and/or I have the authority to surrender the dog to Cavalier King Charles Spaniel Rescue (Qld) Inc. ("the organisation" I acknowledge that the organisation will first endeavour to rehome the dog to an approved applicant who is already on their waiting list should a suitable applicant be available at the time.

I also acknowledge that by agreeing to voluntarily surrender the dog named herein I give my consent to the organisation to publish photos and release details of this dog, at their discretion, via email, mobile phone contact and on appropriate websites which may include but are not limited to www.cavalierrescue.com.au or any such other site as operated by the organisation, Facebook and other social media outlets. The purpose of publishing photos and details of the dog is primarily to secure the most suitable new home for this dog and may also contribute to promoting the work done by the organisation to help maintain positive community support to enable the organisation to continue providing future services.

I consent to the organisation liaising with other rescue and rehoming organisations and agencies in relation to potential suitable new owners for this dog if required.

I consent to the organisation contacting my veterinarian detailed below to discuss and/or obtain previous treatment and veterinary/medical history of the dog and I expressly consent to such veterinarian providing copies of any treatment notes and records to the organisation if requested.
Veterinarian details
Dog's Name / Breed / DOB*
Vet / Clinic Name*
Phone*
Email
example@example.com
I understand that my personal details will remain confidential and the organisation will not release any of my personal details (name, location, contact details) or sensitive information relating to the surrender of this dog to anyone else including to potential new owners, other organisations or agencies or authorised foster carers.

I acknowledge that upon surrendering the dog the organisation becomes responsible for the care and rehoming of this dog and I relinquish my rights to further contact. I understand I may contact the organisation to enquire about the dog and the organisation may contact me further in regards to the dog's health and previous history and to advise once the dog has been suitably rehomed.
Owners Signature*

Clear
Should be Empty:

Surrender Application

Surrender

Owner's Declaration

Veterinarian details