Surrender Request Form

1
Name* This field is required.
First Name
Last Name
2
Phone* This field is required.
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
When do you need to surrender the dog?* This field is required.
6
Dogs Name* This field is required.
7
Sex* This field is required.
Male
Female
8
What breed is the dog?
9
Age* This field is required.
10
How long have you had the dog?* This field is required.
11
Where did you get the dog?* This field is required.
12
Why are you surrendering the dog?
13
Including yourself, how many people of the following ages live in your home?* This field is required.
FEMALE
MALE
00 - 03
Row 0, Column 0
Row 0, Column 1
04 - 09
Row 1, Column 0
Row 1, Column 1
10 - 17
Row 2, Column 0
Row 2, Column 1
18 - 29
Row 3, Column 0
Row 3, Column 1
30 - 59
Row 4, Column 0
Row 4, Column 1
60 +
Row 5, Column 0
Row 5, Column 1
Row 6, Column 0
Row 6, Column 1
00 - 03
04 - 09
10 - 17
18 - 29
30 - 59
60 +
FEMALE
Row 0, Column 0
MALE
Row 0, Column 1
FEMALE
Row 1, Column 0
MALE
Row 1, Column 1
FEMALE
Row 2, Column 0
MALE
Row 2, Column 1
FEMALE
Row 3, Column 0
MALE
Row 3, Column 1
FEMALE
Row 4, Column 0
MALE
Row 4, Column 1
FEMALE
Row 5, Column 0
MALE
Row 5, Column 1
FEMALE
Row 6, Column 0
MALE
Row 6, Column 1
1 of 7
14
What other animals did the dog live with?* This field is required.
no other animals
dogs
cats
Other
15
How does the dog usually behave towards people they know?* This field is required.
never encounter
friendly
afraid
show teeth/growl
snaps
bites
other
men
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
women
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
children
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
men
women
children
never encounter
Row 0, Column 0
friendly
Row 0, Column 1
afraid
Row 0, Column 2
show teeth/growl
Row 0, Column 3
snaps
Row 0, Column 4
bites
Row 0, Column 5
other
Row 0, Column 6
never encounter
Row 1, Column 0
friendly
Row 1, Column 1
afraid
Row 1, Column 2
show teeth/growl
Row 1, Column 3
snaps
Row 1, Column 4
bites
Row 1, Column 5
other
Row 1, Column 6
never encounter
Row 2, Column 0
friendly
Row 2, Column 1
afraid
Row 2, Column 2
show teeth/growl
Row 2, Column 3
snaps
Row 2, Column 4
bites
Row 2, Column 5
other
Row 2, Column 6
1 of 3
16
How does the dog usually behave towards people they DO NOT know?* This field is required.
never encounter
friendly
afraid
show teeth/growl
snaps
bites
other
men
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
women
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
children
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
men
women
children
never encounter
Row 0, Column 0
friendly
Row 0, Column 1
afraid
Row 0, Column 2
show teeth/growl
Row 0, Column 3
snaps
Row 0, Column 4
bites
Row 0, Column 5
other
Row 0, Column 6
never encounter
Row 1, Column 0
friendly
Row 1, Column 1
afraid
Row 1, Column 2
show teeth/growl
Row 1, Column 3
snaps
Row 1, Column 4
bites
Row 1, Column 5
other
Row 1, Column 6
never encounter
Row 2, Column 0
friendly
Row 2, Column 1
afraid
Row 2, Column 2
show teeth/growl
Row 2, Column 3
snaps
Row 2, Column 4
bites
Row 2, Column 5
other
Row 2, Column 6
1 of 3
17
How does the dog usually behave towards animals they know?* This field is required.
never encounter
friendly
afraid
show teeth/growl
snaps
bites
other
dogs
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
cats
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
dogs
cats
never encounter
Row 0, Column 0
friendly
Row 0, Column 1
afraid
Row 0, Column 2
show teeth/growl
Row 0, Column 3
snaps
Row 0, Column 4
bites
Row 0, Column 5
other
Row 0, Column 6
never encounter
Row 1, Column 0
friendly
Row 1, Column 1
afraid
Row 1, Column 2
show teeth/growl
Row 1, Column 3
snaps
Row 1, Column 4
bites
Row 1, Column 5
other
Row 1, Column 6
1 of 2
18
How does the dog usually behave towards animals they DO NOT know?* This field is required.
never encounter
friendly
afraid
show teeth/growl
snaps
bites
other
dogs
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
cats
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
dogs
cats
never encounter
Row 0, Column 0
friendly
Row 0, Column 1
afraid
Row 0, Column 2
show teeth/growl
Row 0, Column 3
snaps
Row 0, Column 4
bites
Row 0, Column 5
other
Row 0, Column 6
never encounter
Row 1, Column 0
friendly
Row 1, Column 1
afraid
Row 1, Column 2
show teeth/growl
Row 1, Column 3
snaps
Row 1, Column 4
bites
Row 1, Column 5
other
Row 1, Column 6
1 of 2
19
Comments on answers above about behavior towards animals and people
20
How does the dog usually react when an unfamiliar person approaches or enters the yard or house?* This field is required.
friendly
afraid
barks
shows teeth/growls
will bite
21
Is the dog housetrained?* This field is required.
yes
no
partially
22
How does the dog let you know they need to go out?* This field is required.
23
Where does the dog spend the majority of their time?* This field is required.
inside the house, runs free
inside the house, crated
outside the house, runs free in yard
outside the house, kennel
outside the house, tied up
Other
24
How many hours a day is the dog left alone without a human?* This field is required.
never
1-3 hours
4-8 hours
9-12 hours
over 12 hours
25
When left alone, is he/she...* This field is required.
outdoors
free roam in home
confined to a room
crated
Other
26
When left alone, does dog usually show any of the following behaviours?* This field is required.
destroy household items
urinate/defecate
bark
cry
none of these
Other
27
When the dog plays, do they typically...* This field is required.
jumps
growls
barks
bites lightly
bites hard
none of these
Other
28
What toys does the dog like?* This field is required.
balls
frisbee
plush
squeaky
tug toy
none
Other
29
What games does the dog like?* This field is required.
fetch
tug
chase
wrestling
none
Other
30
Is the dog scared of anything* This field is required.
yes
no
31
If yes, please explain what the dog is scared of.
32
Please tell us the dog bad habits* This field is required.
33
Is the dog allowed on furniture?* This field is required.
yes
no
34
Where does the dog usually sleep at overnight?* This field is required.
crate
floor
your bed
couch
kids bed
dog bed
outside
Other
35
What commands does the dog know?* This field is required.
no commands known
sit
down
stay
come
leave it
place
heel
Other
36
Describe the dog leash skills* This field is required.
37
Describe the dog reaction if a person or other dog gets near or attempts to take food he is eating.* This field is required.
38
Describe the dog reaction if a person or other dog attempts to take a toy they are playing with.* This field is required.
39
Describe the dog reaction if a person or other dog attempts to take a bone or other treat they have* This field is required.
40
Describe the dog reaction if touched when sleeping.* This field is required.
41
Does the dog have problems riding in car?* This field is required.
yes
no
don't know
42
If yes, please explain what problems the dog has in the car.
43
Has the dog escaped your property 2 or more times in the last 6 months?
yes
no
44
If yes, please explain how the dog got out and if you know why?
45
Has the dog ever attacked or bit a person?* This field is required.
yes
no
46
If yes, please explain what happened at the time of attack or bite. (person)
47
Has the dog ever attacked or bit another dog?* This field is required.
yes
no
48
If yes, please explain what happened at the time of attack or bite. (dog)
49
Has the dog ever attacked or bit a cat?* This field is required.
yes
no
50
If yes, please explain what happened at the time of attack or bite. (cat)
51
Has the dog ever attacked or bit farm animals? (chickens, horses, cows, goat, pig, sheep, etc...)* This field is required.
yes
no
52
If yes, please explain what happened at the time of attack or bite. (farm animal)
53
Please list all veterinarians that have seen the dog, including address and number.* This field is required.
54
Does the dog see a veterinarian at least once a year?* This field is required.
yes
no
55
Is the dog spayed/neutered?* This field is required.
yes
no
56
Are vaccinations current?* This field is required.
yes
no
57
What was the date of the last vaccination?
58
Has the dog been tested for heartworm?* This field is required.
yes
no
59
If yes, what were test results for heartworm
60
Is the dog taking heartworm preventative?* This field is required.
yes
no
61
If yes, when is the next dosage of heartworm preventative due?
62
Is the dog microchipped?* This field is required.
yes
no
63
if yes, Include microchip number
64
Check if the dog has ever shown any of the following behaviours when handled by a vet or groomer.* This field is required.
never done
shows teeth/growls
snap
bite
none of these
examine
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
restrain
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
administer shots
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
bathe
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
clean ears
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
trim nails
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
take blood
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
examine
restrain
administer shots
bathe
clean ears
trim nails
take blood
never done
Row 0, Column 0
shows teeth/growls
Row 0, Column 1
snap
Row 0, Column 2
bite
Row 0, Column 3
none of these
Row 0, Column 4
never done
Row 1, Column 0
shows teeth/growls
Row 1, Column 1
snap
Row 1, Column 2
bite
Row 1, Column 3
none of these
Row 1, Column 4
never done
Row 2, Column 0
shows teeth/growls
Row 2, Column 1
snap
Row 2, Column 2
bite
Row 2, Column 3
none of these
Row 2, Column 4
never done
Row 3, Column 0
shows teeth/growls
Row 3, Column 1
snap
Row 3, Column 2
bite
Row 3, Column 3
none of these
Row 3, Column 4
never done
Row 4, Column 0
shows teeth/growls
Row 4, Column 1
snap
Row 4, Column 2
bite
Row 4, Column 3
none of these
Row 4, Column 4
never done
Row 5, Column 0
shows teeth/growls
Row 5, Column 1
snap
Row 5, Column 2
bite
Row 5, Column 3
none of these
Row 5, Column 4
never done
Row 6, Column 0
shows teeth/growls
Row 6, Column 1
snap
Row 6, Column 2
bite
Row 6, Column 3
none of these
Row 6, Column 4
1 of 7
65
Does the dog have to be muzzled at the veterinarians?* This field is required.
yes
no
66
Does the dog have any past or present health problems?* This field is required.
yes
no
67
If yes, please describe the current health problems
68
Is the dog currently taking any medication?* This field is required.
yes
no
69
If yes, please list medications
70
What type of food does the dog eat?* This field is required.
canned
dry
soft
table scraps
raw
home cooked
71
How many times a day is dog fed?* This field is required.
1 time
2 times
3 times
free feeds
72
How much is fed per feeding?* This field is required.
1 cup
1 1/2 cup
2 cups
2 1/2 cups
not sure, just fill the bowl up
Other
73
Does the dog get treats?* This field is required.
yes
no
74
If yes, what treats does dog like?
75
Please feel free to tell us any other information about the dog you feel is important.
76
Please upload a full body picture of the dog* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
77
Please upload a up close head shot of the dog* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
78
Please upload any records you have for the dog
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
79
Surrender agreement

This form will need to be filled out before we can consider taking a dog into our care; we need to consider why the dog is being surrendered and what Dusty Paws Dog Rescue can do to help it. As we are a volunteer group we rely highly on people to foster these dogs and help us look after them until they are fit for rehoming. We need these questions answered honestly so we don't put our carers, their families or animals in danger with your animal. Along with this form we will also require you to fill out and sign a surrender form surrendering the dog to us; Dusty Paws Dog Rescue You will also be required to provide Dusty Paws Dog Rescue with any vet work you already have for this dog.

We will then sort out a time to come and assess the dog ourselves or get our behaviourist to do it for us. Please note that this does NOT mean that we will take the dog, we need to consider the dogs we have in care first and for most, then the dogs on our waiting list and make sure that we have people available to look after the animal first.
80
Declaration
I acknowledge that I have read and accepted this Surrender Agreement. I agree that all information I have provided to Dusty Paws Dog Rescue is correct and true. I understand that failure to comply with the requirements of this agreement can result in the dog not being able to be surrendered.
I acknowledge that I have been completely truthful and if anything is found to be untrue Dusty Paws Dog Rescue reserves the right to return the dog to me.
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