Dog Surrender Application

Dog Surrender Application

NOTE: Filling out an application does not guarantee we will be able to accept your dog into our agency. Please submit one form per dog you need to surrender. Be 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: intake@rescuevillage.org*
example@example.com
Dog's Name (ONE dog per form is required. We are not accepting applications with more than one dog listed)*
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 give as much detail as possible:*
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 bitten someone? (A bite is defined as breaking skin with teeth that causes bleeding)*

YesNo
If yes, please explain any incidents, with dates:
Has the dog ever attempted to bite someone?*

YesNo
If yes, please explain any incidents:
Please list the age, breed, and sex (and spay/neuter status) of any other dogs living in the home:
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?*
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 address 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
Date

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:*
Would you like to discuss resources that may be available to help you keep you and your pet together?*

Yes, please.This is not an option for me.
I understand that Rescue Village requires an intake fee of $50 per dog to help offset the cost of caring for this dog during it's time with us. Under certain circumstances, we can reduce or waive this fee, but it must be discussed with the Intake Manager prior to your intake appointment*

I understand and can provide the full fee.I understand, but am asking for a reduced or waived fee.
I understand that I MUST have an intake appointment and that the shelter does not accept walk-in surrenders.*

I understandI do not understand and will seek other options
I agree to check my email (including my junk/spam folder) regarding important communication from Rescue Village in regards to this surrender form:*

I agree and will check my email AND junk/spam folderI do not have email and will require a phone call
I understand that Rescue Village is NOT an open admission shelter and that Rescue Village is a limited admission, unlimited stay humane society. I understand my application can be denied for any reason. I understand Rescue Village does not have the capacity for emergency owner surrenders and there will be a wait time.
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 dogs as cage space allows.

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