Senior Dog Sanctuary Surrender Form

Senior Dog Sanctuary Surrender Form
Date

MonthDayYear
Date
Name*
Phone Number*

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your dog's name:*
Age*
Breed*
Weight*
Sex*
Male/Female
Is your pet fixed? (spayed/neutered)*
Yes/No
Microchip Number
How long have you owned your dog?*
How many homes has your dog had?*
Where did you adopt/purchase your dog?*
Please select which options you've already tried in an effort to place your dog:*

Contacted original rescueContacted breederContacted local rescue groupsAdoption/rehoming AdArea shelter/Animal Control
Reason for Surrender:*
Provide as much information as possible.
Is there anything we can do to help you keep your dog?*
Provide as much information as possible.
When does your dog need placement?*

MonthDayYear
Date
Has your dog bitten anyone in the last 10 days? *
If yes: Who Was Bitten?
When was the bite incident & what City?
Was Animal Control Involved?

YesNo
Did the incident break the skin?

YesNo
Has your dog ever:*

BittenScratchedLunged or AttackedNone of the above
Please Explain the Circumstances
Your current Veterinarian's Name*
Your current Veterinarian's Phone number*
Date of Last Vet Visit*
Is your dog currently vaccinated?*

YesNoOther
Is your dog current on heartworm testing/preventatives?*

YesNoOther
Please list any past or present injuries, treatments or other medical history*
Check all of the following that describe your dog*

ActiveMedium EnergyCouch potatoVery chattyBarks at appropriate timesBarks when left aloneQuietPlayfulFriendlyLikes to be touchedAffectionateAlways at your sideShyIndependentFearfulNervousSeparation anxietyProtectiveIndoor dogOutdoor dogFence JumperEscape artistDiggerPrefers menPrefers womenWorked livestockUsed for huntingFriendly to dogsFriendly to catsFriendly to kids outside the homeFriendly to unknown adults
Is your dog housetrained? (Select all that apply)*

Yes, uses bathroom outside onlyYes - inside on pads/litterbox onlyYes - a combo of inside/outsideHas occasional accidentsNot housebrokenIncontinent due to age/medical
Is your dog crate trained? (Select all that apply)*

YesUse when unsupervisedUse at nightDog loves the crateDog tolerates the crateDog does not like the crateDog is destructive in crateNever Exposed/Used
Describe how your dog has done in a boarding facility and/or daycare:*

Dog was not anxiousDog was anxious/cried/barkedDog was in playgroups with other dogsNever exposed/used
Can your dog go up and/or down stairs?*

Yes UpYes DownNo UpNo Down
What is your dog's history with children?*

Lived withExposed toNo history with children
What Ages
List ages and separate ages with commas
Would you recommend your dog live with children in the future?*

YesNoOther
If No or Other, briefly explain why.
What is your dog's history with other dogs?*

Lived withExposed to (dog parks, on walks)No history with dogs
Would you recommend your dog live with dogs in the future?*

YesNoOther
If No or Other, briefly explain why.
Has your dog lived with or been exposed to cats?*

Lived withExposed toNo history with cats
Would you recommend your dog live with cats in the future?*

YesNoOther
If No or Other, briefly explain why.
How long is your dog home alone daily?*
What does your dog dislike or fear?*
What does your dog like or enjoy?*
Does your dog know any commands or tricks? If so, what do they know?*
Where is you dog kept when unsupervised?*
Where does your dog sleep at night?*
How does your dog travel in a car?*

Loves car ridesTolerates themIs anxiousPrefers not to go anywhere in the carGets carsickOther
What type of food do you feed your dog?*
How is their appetite? (Select all that apply)*

Why do you never feed me? Give me more!I'll have my regular, pleaseVariety is the spice of lifePicky Prince/PrincessHand feed me or I'll go on strike!I'd like my privacy, pleaseI don't like dining aloneOnly peasants eat dog food, I'll have some of yours
Please describe the ideal home for your dog:*
Please Upload a Clear Picture of the Dog*

Upload a File

Cancelof
My signature below certifies that I am the owner of (or have the authority to surrender) the dog described above. I certify that to the best of my knowledge I have disclosed all information about the dog concerning health, behavior, history, and anything else that may affect the safe placement of the dog in a new home and that all statements made above are true and correct. I understand once my dog is accepted, the Senior Dog Sanctuary of MD shall have sole and exclusive legal rights to make all outcome decisions deemed appropriate and that SDS is not obligated to communicate the outcome of the dog to me or any other party.
Sign here*

Clear
**IMPORTANT - PLEASE READ FOR NEXT STEPS FOLLOWING SUBMISSION OF APPLICATION**

We ask for your patience as we receive a large number of requests on a daily basis.
We will respond to your application within 5 days.

**Check your inbox + spam folder for a response to your application from intake@sdsanctuary.com**

We are proud to provide a compassionate environment with the best possible medical care for the senior dogs who join our Sanctuary. This is made possible through donations of our supporters. If you are able, we appreciate any donations made to our cause!
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