Surrender Application
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
Referred by
Please let us know the reason for the surrender of the dog
Dog's Information
Dog's Name
Gender
Male
Female
Spayed/Neutered
Yes
No
Date of Birth
Color
Weight
Age
Dog's Breed
Purebred
Yes
No
AKC Registration #
Breeder
Breeder's Contact Information
Microchipped
Yes
No
If yes, Brand and Microchip #
Is your dog hearing and/or vision impaired
Vision
Hearing
Both
N/A
Does your dog live with any other animals(type, sex, age)
Check all that apply for your dog
Rides in cars well
Likes cats
Likes other dogs
Likes playing with toys
Housebroken
Crate trained
Obedience trained
Food aggressive
Digs in yard
Jumps on people
Barks excessively
Walk on lead
Come when called
Chews/Destroys items
Shy
Nervous
Submissive
Laid back
Dominant
Needy
Excitable
Easy going
Fearful
Other
Will your dog jump
Short 3ft fence
Tall 6ft fence
Does NOT jump fence
Please list the commands/hang signals that your dog understands
Please list any special tricks or training tricks
Has the dog bitten or snapped at a human
Yes
No
Has the dog ever killed or bitten another animal (including, but not limited to another dog)
Yes
No
Where does your dog sleep at night
Dog's Feeding Information
Dog Food Brand
How many meals per day
How much food per meal
Meal Times
Medical Information
Veterinarian's or Clinic's Name
Veterinarian Clinic's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Veterinarian Clinic's Phone Number
-
Area Code
Phone Number
Veterinarian Clinic's Email
example@example.com
Vaccination Dates
Rabies
Yes/No and Date
Bordatella
Yes/No and Date
DA2PP
Yes/No and Date
Lepto
Yes/No and Date
Last Hearworm Test
If positive, was there treatment given?
Current Monthly Heartworm
Include the Brand
Any Medical Issues/Allergies
Any Surgeries
MEDICAL RELEASE: Upon checking this box, you agree to notify your veterinary clinic and give permission for release of all your dog's medical records to Woah Nellie Great Dane Rescue Inc. Also certifying that the information completed on this form is true and accurate.
RELEASE OF PET OWNERSHIP: Upon completion of your signature below, you are releasing and transferring ownership to Woah Nellie Great Dane Rescue Inc. Upon checking this box, you understand that after completion of this release you shall have no interest or right to the decisions regarding the above mentioned dog.
Upon checking this box, I certify that the information completed on this surrender application is accurate. I understand that this information may be shared by Woah Nellie Great Dane Rescue Inc with other rescue groups to ensure the best interest in the dog.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: