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Dog Surrender Form

Full Name

Phone Number

Email Address

Street Address

City/State/Zip

Dog's name:

Dog's age:

Breed:

Upload a picture of your dog:

Behavior Checklist:

Check the corresponding boxes to inform Animal House Retail for Rescue's Canine Behavior Specialist as to whether or not your pet has any behavioral concerns worth noting or working on with a professional trainer while in shelter or in foster. Any items marked Yes will be worked on with a trainer. Any items marked Unknown will be evaluated. Please use the Notes question at the bottom of this form to elaborate on any items which you think require additional information

Is your dog an escape artist?

Does your dog struggle to be confined (in a crate)?

Is your dog reactive to seeing people when on leash?

Is your dog reactive to seeing dogs when on leash?

Is your dog destructive in the home?

Does your dog get anxious in the car/carsick?

Is your dog housebroken/housetrained?

Is your dog protective of their food?

Is your dog protective of their toys?

Is your dog protective of their bed/space?

Is your dog protective of their siblings (if any)?

Is your dog protective of their handler?

Is your dog okay with children 0-12?

Is your dog okay with children 12+?

Has your dog ever lived with other dogs?

Has your dog ever coexisted with dogs smaller than them?

Has your dog coexisted with dogs larger than them?

Has your dog ever injured a dog?

If yes, provide details of the incident/injury to another dog:

Has your dog ever lived with cats?

Has your dog ever injured a cat?

If yes, provide details of the incident/injury to a cat:

Has your dog been fearful of children?

Has your dog been fearful of men?

Has your dog been fearful of women?

Does your dog enjoy playing with toys?

Does your dog enjoy treats?

Has your dog ever injured a person?

If yes, provide details of the incident/injury to a person:

What Level of Training does your dog have? Check all that apply.

Activity Level:

Where does your dog sleep and/or where do they spend most of the day

What brand dog food does your dog eat? What is their feeding schedule?

Please share with a potential adopter some great qualities about your dog:

Does your dog have any medical conditions that require treatment? Has she/he had any conditions in the past that have been treated?

Has your dog had any vaccinations, heartworm testing, spayed/neutered? If so, please describe:

Upload Medical Records Here:

Please describe the actions you have taken so far to keep your dog and why those actions have not worked:

If your dog was a rescue, have you contacted the organization to see if they can take the dog back? What is the name of the rescue that you adopted him/her from?

Notes/Reason for Surrender:

Relinquishing Receipt for Animal Surrendered to Animal House Retail for Rescue by Owner

I hereby give Animal House Retail for Rescue permission to request all medical history and medical records from my Veterinarian for the animal I am relinquishing.

I acknowledge that my signature on his receipt relinquishes all claims of ownership of the animal(s) described. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, suites, or otherwise against Animal House Retail for Rescue with respect to this animal(s). I understand that Animal House Retail for Rescue will not return this animal to me, once left in its care, under any circumstances, unless otherwise approved by the Animal House Retail for Rescue Executive Director.

Signature:

Signature

Today's Date: