Dog Surrender Application

Dog Surrender Application

Filling out an application does not guarantee we will be able to accept your dog into our shelter. For appropriate review of your application and to prevent delays, we ask that you are as detailed as possible when completing this application.
Please note: If you are completing this application for a dog that was adopted from us within the past 30 days you will hear from us within 24-48 business hours Monday-Friday.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Phone Number*
Please enter a valid phone number.
Email-If you do not have email write: animalintake@rescuevillage.org*
example@example.com
Dog's Name *
One pet per form. If you have multiple dogs you want to surrender, you will need to complete multiple applications.
Dog's Age*
Male/Female?*
Spayed or Neutered?*
Breed*
If you are able, please upload a photo of the dog here:

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How long have you owned this dog?*
Where did you originally get the dog?*
Have you attempted to contact and return the dog to the person/place you originally got them from?*

Yes,NoOther
What is the reason you need to surrender this dog? Please provide as much detail as possible:*
We must ask many questions to collect an accurate history on owner surrender requests. If you are not able to provide details about your dog on this application, we will be unable to contact you regarding your request.
Where does the dog spend most of their day?*
How many hours is the dog left home alone? *
Where is the dog when left home alone, and how do they react?*
Have you ever put the dog in a crate?*
How is the crate utilized? Check all that apply:

Never crated / NAHome aloneOvernightDisciplineFeedingSeparation from other animals/peopleOther
How do they behave in a crate?
Is the dog housebroken?*

Yes, completelyMostly, rarely has accidentsSomewhat, has occasional accidentsNo, not at all
When the dog goes outside, how do they spend their time? Check all that apply*

Walked on leashFree roam of yard, not fencedInvisible fenceFree roam of fenced in yardOverhead trolley runOutdoor Dog Run/PenOther
Where does the dog sleep at night?*
Who lives in the home? Check all that apply:*

Adult menAdult womenSenior citizensInfant(s)Children aged 2-5Children aged 6-9Children aged 10-12TeenagersOther DogsCatsOther
How does the dog behave around children?*
Have they ever had a negative reaction to a child or do they ever need a break from the children? If so, please explain?*
Does the dog ever growl at people? If so, please explain:*
The dog is protective of: (Check all that apply)*

HomeFoodTreatsBedCrateFamily/PeopleNone of the above / NAOther
Please explain any protective behavior:*
Has the dog ever chased or attempted to attack or bite a person? *
If yes, describe the incident(s) in which the behavior occurred, including dates.
Has the dog ever bitten a person?*
If yes, describe the incident(s) in which the behavior occurred, including dates.
Has the dog ever seriously injured or killed a person?*
If yes, describe the incident(s) in which the behavior occurred, including dates.
Has the dog previously been designated a nuisance, dangerous, or vicious dog?*
If yes, indicate the designation that was assigned, the date of designation, and in which county or city the designation was made.
Please list the age, breed, and sex (and spay/neuter status) of any OTHER dogs living in the home. Write "N/a" if the dog does not currently live with other dogs.
Do not list information for the dog you are applying to surrender.
How does the dog behave with the other dogs in the home?
How does the dog react to dogs they do NOT know?*
Has your dog ever visited a dog daycare/boarding facility? If so, how do they respond?*
How does your dog behave with cats they do not know?*
How does the dog behave on leash around strangers?*
How does the dog behave on leash around other dogs?*
Has the dog ever attacked and injured another animal (including wildlife)? If so, please explain:*
What reaction does the dog have to visitors entering the home?*
Can you remove an object from the dog's mouth?*

YesNo
Can you touch the dog or take away it's food when it's eating?*

YesNo
How does your dog behave in the car?*
Is your dog afraid of anything? If so, what are they afraid of?*
Has your dog ever received any formal behavioral training? If so, please list trainer/company below:*
What commands does your dog know?*
What are some of your dog's favorite things (toys, places, activities)?*
Does your dog have any bad habits or behavioral needs?*
How do you correct your dog's bad habits and how do they react?*
What brand of food do you feed your dog?*
Has the dog ever been to a vet?*

YesNo
How do they behave at the vet?
Who is your current Veterinarian?
Date of last DHPP vaccine:

MonthDayYear
Date
Date of last Rabies vaccine:

MonthDayYear
Date
Please upload any medical records here (NOTE: receipts and invoices are NOT medical records):

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Please list any significant health issues the dog has:*
Please list any current medications, including heartworm/flea preventative the dog is on AND when these medications were last given:*
I understand that Rescue Village has a service area and that if I am outside of that service area, I may be directed to other agencies for assistance depending on the situation, shelter capacity, waiting list length, etc.*

I understandI do not understand and will seek out options. I understand by selecting this option I will not be contacted.
I understand that Rescue Village requests an intake fee of $50 per dog to assist with cost of care.*

I understand and can provide the full fee.I understand, but am asking for a reduced fee.
I understand that I MUST have a surrender appointment and that Rescue Village does not accept walk-in surrenders.*

I understandI do not understand and will seek out options. I understand by selecting this option I will not be contacted.
I agree to check my email (including my junk/spam folder) regarding important communication from Rescue Village in regards to this surrender application.*

I agree and will check my email AND junk/spam folder.I do not have email and will require a phone call instead.
I understand that Rescue Village is NOT an open admission shelter, meaning not every application is able to be accepted. I understand that Rescue Village is a limited admission, unlimited stay humane society and that my application can be denied for any reason.*

I understandI do not understand and will seek other options. I understand that by selecting this option I will not be contacted.
I understand that if my application is accepted, I may be placed onto a waiting list as Rescue Village never euthanizes for space. I understand that this waiting list may be lengthy.*

I understandI am unable to wait and will seek out other options. I understand by selecting this option I will not be contacted.
Please understand that pets often behave differently in a shelter environment than they do at home or in their outdoor home due to stress and unfamiliar surroundings. For this reason, shelter surrender is not always the best or most appropriate option for every pet.*

I understandI do not understand and will seek out options. I understand by selecting this option I will not be contacted.
Rescue Village reserves the right to decline surrender requests at its discretion and for any reason. We kindly ask that all interactions with our staff remain respectful. Any use of inappropriate behavior may result in refusal of services.
By signing below, I understand that Rescue Village has the right to deny my surrender form for any reason. I also understand that if my surrender form is accepted, there may be a lengthy wait because Rescue Village does NOT euthanize animals for time or space reasons and can only schedule in animals as species appropriate space allows.*

Clear
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Dog Surrender Application

Please note: If you are completing this application for a dog that was adopted from us within the past 30 days you will hear from us within 24-48 business hours Monday-Friday.