Midwest Border Collie Rescue Relinquishment Form

Relinquishment Form

Midwest Border Collie Rescue
Is this an owner or a shelter relinquishment?

Owner relinquishmentShelter relinquishment
Shelter or Owner Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Shelter or Owner Contact*

First NameLast Name
Shelter Website (if applicable)*
Dog's Name*
Sex of Dog*

MaleFemale
Dog's Age*
Dog's Height and Weight*
Purebred or Mix*

Purebred with papersPurebred no papersMix
Was this dog purchased from a breeder?

YesNoDon't know
If purchased from a breeder, did you contact them?

YesNo
How long has the dog been at your shelter/How long have you had your dog?*
(If shelter) Was the dog turned in or was it a stray?*

Owner turn inStray
For shelter: If the owner turned in the dog, what was the reason given?
For owner: Why are you relinquishing your dog?
Has the dog ever bitten? If yes, explain.*
List the dog's general overall health and any issues.*
Dog's history - Check all that apply*

Spayed or neuteredHouse trainedCurrent on RabiesCurrrent on DistemperTested for Heartworm (Negative)Tested for Heartworm (Positive)Not tested for Heartworm
Has the dog met children? If yes, how is it with children (what ages)?*
Has the dog met other dogs? If yes, was the dog on or off leash? What kind of dog was the other dog (size relative to each other, temperament, etc.) How did the dog do?*
The dog reacts in a negative or fearful way to the following (please check all that apply)*

Other dogsStrangersMenWomenChildrenCratesCatsPettingGiving a TreatGuarding FoodTaking away a toyStepping into a dog's spaceDirect eye contactTouching feetTouching tailThunderstormsLoud noisesNone of the above
What commands does the dog know?*

SitStay/WaitOff/Lie DownLeave It/Drop ItNoLoose Leash Walking/Heel
Which of the following terms would you use to describe the dog (Check all that apply).*

FriendlyAnxiousShyScaredDefensiveDestructiveAffectionateOutgoingSuspiciousCautiousProtectiveTrainableDifficultStubbornObedientLethargicHyperHappy Go LuckyAnxious to PleaseCalmDrivenQuietFearfulDominant
Please list any behaviors that need improving (I.e. barking, jumping on people, recall, fearful of noises, etc.)*
Please attach pictures of the dogs front end, back tail, right side and left side*

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