Surrender Form
IMPORTANT NOTE: Completion and submission of this form in NO WAY transfers custody or ownership of any dog to the care of Collie Rescue Network. The purpose of this form is for informational purposes only and to help CRN use the information given here to determine if we are able to accept your dog into the rescue program. If your dog is accepted into the program, a volunteer will be in touch with your via phone or email. If for any reason your dog is not accepted into the program a volunteer will be in touch with information for possible alternatives including other rescue groups or shelters in your local area who might be better able to assist you. COLLIE RESCUE NETWORK RESERVES THE RIGHT TO REFUSE THE ACCEPTANCE OF ANY DOG, AT ANY TIME, FOR ANY REASON, INTO THEIR RESCUE PROGRAM.
Contact Information:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Cell Number
-
Area Code
Phone Number
Email
*
example@example.com
Description of your dog:
Name:
*
Age:
*
Gender:
*
Coat (rough/smooth):
*
Microchip:
Date of Birth:
Spayed/Neutered:
*
Coat Colour:
*
Is this dog a mix:
*
If yes, what breeds:
General Information:
Where did you acquire this dog:
*
Breeder's Name and Phone Number:
Was the Breeder contacted:
Yes
No
Unknown
Other
Can the Breeder take the dog back:
Yes
No
Unknown
Other
How many owners has this dog had in their lifetime:
*
Age of the dog when you acquired him:
*
Has this dog ever been neglected/abused:
*
Yes
No
Unknown
Other
Is this dog used to being mainly indoors or outdoors:
*
How many hours each day is this dog used to be alone:
*
When alone, is this dog crated, left loose or left outdoors:
*
Is this dog crate trained:
*
How often does this dog have potty accidents in the house:
*
Does he know basic obedience? If yes, what commands are known:
*
Can this dog walk up and down stairs:
*
Can this dog walk on linoleum/hardwood:
*
Behaviour & Temperament
Is this dog protective? If yes, of whom:
*
Does this dog growl at strangers:
*
How does this dog react to someone knocking at the door:
*
Has this dog ever bitten or caused injury to a person or another animal:
*
If yes to above, please provide details here:
Does this dog have any fears (thunder, brushing, etc.):
*
Does this dog chase cars:
*
Does this dog chase skateboards/bikes, etc.:
*
How does this dog react to other dogs or to people approaching when on leashed walks:
*
How would you describe your dog (check all that apply):
*
Friendly
Reserved
Laid-back / calm
Stubborn
High Energy
Outgoing
Dominant
Submissive
Likes & Dislikes:
Check all that apply:
*
Likes male dogs
Likes female dogs
Likes cats
Likes children
Likes men
Likes women
Destructive in the house
"Barker" indoors or outside
Jumps fences
Jumps on people
Likes car rides
Likes being brushed
Guards food or treats
Takes treats gently
Needs a fenced yard
Timid with new people
Likes toys
Likes to chew
Health & Diet History
Date of last vaccinations:
*
Date of last rabies shot:
*
Date last heartworm tested:
*
Heartworm test result:
*
Brand of Heartworm preventative used (and when last used):
*
Date spayed/neutered:
*
Date of last physical exam:
*
Name of your veterinarian:
*
First Name
Last Name
Phone Number of your veterinarian:
*
-
Area Code
Phone Number
What brand of food does your dog like to eat:
*
List all past and current medical issues or illnesses:
*
Comments:
Additional Information:
Reason for surrendering your dog:
*
Comments (please add anything you feel a foster family or the eventual new furever family might need to know):
Submit
Should be Empty: