Canine Department Request to Surrender

Canine Department Request to Surrender
Required Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Dog Details:
Dog's Name*
Dog's Age*
Dog's Breed*
Dog's Color or Markings*
Dog's Gender*

MaleFemale
Is your dog spayed/neutered?*

YesNo
Is the dog microchipped?*

YesNo
Are you the current owner of the dog?*

YesNo
How long have you had the dog? *
My dog stays primarily: *
Where did you get the dog? *
If you selected "Another Shelter" or "Other Shelter" Please Specify
Please explain why you are choosing to surrender your dog: *
Please explain the steps you have taken to resolve the issue or rehome your pet: *
Has the dog been to a vet within the last year?*

YesNo
Who is your current veterinarian?*
Does the dog have any old/new injuries or health issues?*

YesNo
If yes, please explain.
My Dog has successfully lived with: (Select all that apply)*

MenWomenChildren under 5 yrsChildren over 5 yrs
If there have been any issues with people, please explain:
My dog has lived with the following dogs (please list breed, age, gender):
My dog has lived with cats*

YesNo
If yes, does your dog: (select all that apply)

ChasePlayIgnore
Has your dog ever bitten, nipped, or snapped at any person or animal?*

YesNo
If yes, please explain:
Has your dog ever growled or snapped at any person or animal over food or toys?*

YesNo
If yes, please explain:

Please tell us information on the following behaviors that you have observed:

	Yes	No	If Yes, explain
Separation or other anxiety
Chewing or Digging
Excessive Barking
Chasing Cars, animals, people, etc
Protective of house, yard, family, etc
Jumping
Biting or Aggression
Fears

Household items my dog destroys while I am home (Please Select All that Apply)

WoodworkWallsWindorsDoorsFurnitureToysClothingShoesOther
Household items my dog destroys while I am NOT home (Please Select All that Apply)

WoodworkWallsWindorsDoorsFurnitureToysClothingShoesOther
When outside does your dog: (select all that apply)*

Remain on LeashWander FreelyRemain in fenced yardStay on a tie-outEscape from fenced yardOther
When on a leash does your dog: (select all that apply)

PullWalk politelyLunge at other dogs or poepleOther
When in a crate does your dog: (select all that apply)

EscapeSleepWhineBarkUrinateDefecateRelax
When in a car does your dog: (select all that apply)

RelaxWhineSleepPaceOther
Is your dog permitted to sit or sleep on furniture?*

YesNo
How often do you take your dog outside to use the bathroom?
Does your dog have accidents inside the house?*

YesNo
If yes, how often?

DailyA few times a weekA few times a monthRarely
Commands that my dog knows: (Select all that apply)*

SitShakeLay DownStayRoll OverLeave itDrop itOther
Anything else we should know about your dog?
I acknowledge:

1. I am relinquishing all claims of ownership associated with this animal.

2. I have filled out this form accurately and with true information regarding this animals, and I understand that providing false infomration only negatively impacts the animal and their chance of finding a new home.

3. If and when this animal is made available for adoption is at the sole discretion of the Humane Animal Treatment Society.

4. The Humane Animal Treatment Society does, in certain circumstances, humanely euthanize animals for unmanageable aggressive behavior or serious health issues that exist upon intake or arise during the animal's stay.

5. I understand that by relinquishing this animal I will be unable to adopt from the Humane Animal Treatmetn Society for a minimum of one year from today's date.
Signature*

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