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?
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
Preventative given?
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?
Getting to Know the Dog
Is the dog housebroken?
Is the dog good with other dogs?
Is the dog good with cats?
Is the dog good with young children?
Is the dog good with older children?
Is the dog good with men?
Is the dog good with women?
Does the dog have any aggression or behavioral issues?
If yes, please explain:
Has the dog ever bitten anyone?
If yes, please explain:
Does the dog have any fears?
If yes, please explain:
Is the dog crate trained?
If yes, how many hours in the crate at a time?
Where does the dog stay when you are not home?
Where does the dog sleep at night?
Where does the dog eliminate? (Check all that apply)
What type of food does the dog eat?
What brand of dog food does the dog eat? (Please be specific)
How often does the dog eat?
What commands does the dog know?
Has the dog had any formal obedience training?
If yes, please explain:
What toys does the dog like to play with?
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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Wisconsin Boston Terrier Rescue Surrender/Release Form

Medical Information

Getting to Know the Dog

Make a donation via PayPal (not required)