Surrendering Form

Dog's Name*

Today's Date*

Your Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Dog's Microchip # and company

Color of dog*

Sex*

Spayed/Neutered*

Tail docked?*

Ears Cropped?*

Date of Birth/Age*

How Long Owned?*

Current Veterinarian Name*

Current Veterinarian Phone #*

Is the dog current on the following? (Please email veterinary records as back up)

Rabies (date of last shot and cert #)*

DHLPP?*

Bordatella?*

Date of Last Heartworm Test*

Date Last Heartworm Preventative Was Given*

Why is the dog being given up?*

Where did you get the dog?(if from a breeder, shelter or rescue please provide that information:*

Where was the dog allowed when you were home?*

Crate
Outside
Whole House
Specific Room

Where was the dog kept when you were not home?*

Crate
Outside
Whole House
Specific Room

How long was the dog left alone each day?*

Where did the dog sleep?*

Who lived with the dog? (specify ages of all people)*

How did the dog behave around others living in the home? Were there any issues?*

How did the dog behave around children?*

Would you recommend this dog be placed in a home with children?*

If so, what ages?

The dog knows how to:*

Sit
Stay
Come
Lie Down
Heel
Walk nicely on Leash
Ride Nicely in Car

Does the dog know how to do anything else?

Was the dog taken to obedience class or did you use a private trainer? Please provide info on where you went or who you consulted:

How does the dog do for having toenails trimmed?*

Does the dog have any bad habits in the house if unsupervised?*

Describe any fears the dog may have of people or things in detail:

Is the dog housebroken?*

Crate trained?*

Does it have accidents in the house?*

If yes, how often? What have you done to help this?

When outside, the dog is:*

In a fenced yard
Tied out

Does the dog have any outside habits we should be aware of (i.e. jumping fence, digging)?*

Are there any animals the dog does not get along with?*

Has it ever killed another animal that is smaller like a cat?*

Does the dog get along with other dogs?*

Explain any issues in this area:*

Does the dog have any injuries or health issues? Please explain in detail any medications it must take:*

How often do you feed the dog?*

Food brand:*

Please list any vitamins or supplements you use for dog:*

What toys does the dog like?*

Has the dog ever bitten, snapped or growled at anyone? Explain situation and results:*

Is there anything the dog will chase?

Do you allow the dog on any furniture?

Do you allow the dog on your bed?*

Give us the best description of your dog's personality:*

Notes:

To my knowledge, no one has been bitten or scratched by this animal in the past fourteen (14) days. To my knowledge, the above answers are true and correct. I understand a give-up fee may be required. None of the answers to the above questions will necessarily exclude any dog from being taken into our program. All of the members of our organization are volunteers and all of our dogs are “fostered” in private homes, which often include other dogs, both big and small, cats, other pets, children, etc. Being as truthful as possible enables us to place the dog in an appropriate foster home without endangering our volunteers.*

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Surrendering Form

Surrendering Intake Form

Is the dog current on the following? (Please email veterinary records as back up)

Our adoption area encompasses Nebraska, Iowa, and South Dakota.

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