Surrender/Release Form

Wisconsin Boston Terrier Rescue Surrender/Release Form
Name*

First NameLast Name
Today's Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Daytime Phone Number

Area CodePhone Number
Evening Phone Number*

Area CodePhone Number
E-mail address*
Name of dog being surrendered*
Dog's Breed?
Age (approximate)*
Dog's date of birth (if known)
Gender*
Spayed/Neutered?*

YesNo
How long have you had the dog?
Where did you get the dog?
Reason for surrender?*
Medical Information
Date of last DHLP-P
Date of last Rabies vaccination
Any other vaccines given? (please list and give dates given)
Last heartworm test
Result of Heartworm test

NegativePositive
Preventative given?*

YesNo
Brand?
Date of last dose?
List any health conditions (if any)
Is the dog on any medications? If so, please list type and dosage and what they are for.
Current Vet's name*
Current Vet's phone number*

Area CodePhone Number
Current Vet's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Have you contacted your current vet to give them permission to release the dog's records to WBTR?*

YesNo
Getting to Know the Dog
Is the dog housebroken?*

YesNo
Is the dog good with other dogs?*

YesNo
Is the dog good with cats?*

YesNo
Is the dog good with young children?*

YesNo
Is the dog good with older children?*

YesNo
Is the dog good with men?*

YesNo
Is the dog good with women?*

YesNo
Does the dog have any aggression or behavioral issues?*

YesNo
If yes, please explain:
Has the dog ever bitten anyone?*

YesNo
If yes, please explain:
Does the dog have any fears?*

YesNo
If yes, please explain:
Is the dog crate trained?*

YesNo
If yes, how many hours in the crate at a time?
Where does the dog stay when you are not home?*

Confined to a crateConfined to a certain part of the houseRun of the house
Where does the dog sleep at night?
Where does the dog eliminate? (Check all that apply)*

Fenced in yardOn a leash on walksOn a chain or trolleyLoose in the yard
What type of food does the dog eat?*

Wet foodDry foodCombination of wet/dry food
What brand of dog food does the dog eat? (Please be specific)
How often does the dog eat?*

Once a dayTwice a dayFree fed
What commands does the dog know?

SitLie downStaySpeakComeFront
Has the dog had any formal obedience training?*

YesNo
If yes, please explain:
What toys does the dog like to play with?*

KongStuffed animalsBallChewiesRopeOther
Do you have anything else you would like to share or comment on?
By submitting this form I voluntarily surrender the following animal to Wisconsin Boston Terrier Rescue. I release all rights to this animal and understand I cannot reclaim this animal at any time. I will provide any health records that I have to Wisconsin Boston Terrier Rescue. I further understand that Wisconsin Boston Terrier Rescue may choose to notify me when a successful placement is made, but will not release the name and address of the adopter. I understand this in done in the best interest of the dog. In extenuating circumstances, this requirement may be waived. I further note that I will not be charged a surrender fee, but that Wisconsin Boston Terrier Rescue will accept a donation at this time if I wish to make it.
Make a donation via PayPal (not required)

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Please upload some pictures of your dog.

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Wisconsin Boston Terrier Rescue Surrender/Release Form

Medical Information

Getting to Know the Dog