Step 1 of 9 11% Background Information* denotes required fieldDog's Name* Sex* Male Female Age/Date of Birth (if known)* Age when you acquired* Spayed/Neutered?* Yes No Date of spay/neuter (if known) Color and Approximate Weight* Where did you get this dog?* Breeder (provide name if known in the space below) Pet Store Shelter/Rescue Internet Site Friend/Neighbor Found as Stray Gift Other (please describe in space below) Describe "Other" or Breeder's Name (if known) Breed of Dog* Is this dog a purebred?* Yes No If not, we may request to see pictures of the dog or see the dog in person prior to determining whether we can accept him/her into our program.Are the dog's AKC papers and/or pedigree available? Yes No Note: These are not required for acceptance into our program.Is the dog tattooed/microchipped?* Yes No If yes, please list registration #: Why are you giving up this dog? (Please be honest.) Current Household HistoryAvg. hours/day the dog spends indoors:* Avg. hours/day the dog spends outdoors:* Environment when outdoors:* Allowed to roam Fenced yard Kenneled Tied/chained On runner/cable Leash walked Has the dog been trained to an electronic (invisible) fence?* Yes (If yes, please describe any problems in the space below) No Electronic/invisible Fence Issues (if applicable): Describe typical leash manners Okay Pulls Lags Afraid of leash Avg. hours/day the dog spends alone:* Dog's location when left alone:* Outdoors Free in the house Confined to a room(s) Crated Does the dog get anxious/upset when left alone?* Yes (If yes, please describe in the space below) No Anxious behavior when left alone (if applicable): Has the dog been allowed on furniture?* Yes No Where does the dog sleep at night?* Is the dog crate trained?* Yes No If yes, how often is the dog crated? Daily (please list avg. hours in space below) Overnight Occasionally Rarely/never Behavior in crate: Loves Tolerates Barks/whines Highly stressed Not applicable Does the dog have difficulty with steps?* Yes (If yes, please describe in the space below) No Please describe step difficulty (if applicable): How often does the dog travel by car?* Often Sometimes Rarely Behavior in car: Loves Indifferent Hates/gets carsick Not applicable House Training HistoryIs the dog housebroken?* Yes No Sometimes How many times/day does the dog go out to potty?* How does the dog signal a need to go out?* Does the dog have accidents in the house?* Yes No If yes, how often? Daily Few times/week Few times/month If yes, what kind of accident? Urinates Defecates Both How long can the dog typically go without relieving itself?* Not at all 1-3 hours 4-8 hours 9-12 hours 12+ hours Interaction with People & Other AnimalsHousehold members: MenPlease list the ages of household members the dog currently lives with Household members: WomenPlease list the ages of household members the dog currently lives with Household members: ChildrenPlease list the ages of household members the dog currently lives with Please rate the dog's typical reaction to men in the household*FriendlyAfraidShows teethGrowlsSnaps/BitesNo ReactionPurposefully ignoresNot ApplicablePlease rate the dog's typical reaction to women in the household*FriendlyAfraidShows teethGrowlsSnaps/BitesNo ReactionPurposefully ignoresNot ApplicablePlease rate the dog's typical reaction to children in the household*FriendlyAfraidShows teethGrowlsSnaps/BitesNo ReactionPurposefully ignoresNot ApplicablePlease rate the dog's typical reaction to strangers/new people*FriendlyAfraidShows teethGrowlsSnaps/BitesNo ReactionPurposefully ignoresNot ApplicablePlease rate the dog's typical reaction to vet appt.*FriendlyAfraidShows teethGrowlsSnaps/BitesNo ReactionPurposefully ignoresNot ApplicableHow much time does the dog typically spend with children?*DailyWeekends onlyOther (please describe below)No contactWhat other animals has the dog lived with? Dogs (Male) Dogs (Female) Cats Other (please note below) Please use this space to describe other animals the dog has lived with: Amount of interaction with dogs outside the home:*Meets on walksRegular visits with known dogsGoes to dog parkRarely meets other dogsReaction to other dogs:*Friendly/PlayfulToleratesAfraidBarksLungesShows teeth/growlsSnaps/bitesIndifferent/no reactionNever been around other dogsHas the dog ever been in a fight with another dog?* Yes (if yes, please describe below) No If yes, please describe fight/incident: Reaction to cats:*Friendly/PlayfulToleratesAfraidBarksLungesShows teeth/growlsSnaps/bitesIndifferent/no reactionNever been around cats Behavioral InformationWhat kind of obedience training has your dog had?* None I/we trained ourselves (at home) I/we used a trainer for group or individual classes Please describe your general training methods: How do you correct or discipline the dog for inappropriate behavior? Have you ever used a shock collar (remote trainer)? Yes No Responsiveness to training:ExcellentGoodFairPoorKnown commands (please check all that apply): Sit Down Come Stay Fetch Give Paw Other How would you describe your dog's energy level?* High Medium Low Does your dog have problems with any of the following ?(Please check all that apply and use the space below to describe details) Jumping on people Mouthing (grabbing clothes, arms, legs with mouth) Inappropriate chewing Stealing food from counter/tables Getting into trash Running away Jumping/climbing fences Digging Nuisance barking Chasing/hunting birds, rodents, etc. Urinating when excited/nervous Mounting people (humping) Mounting other dogs Describe:Have you ever consulted a trainer/behavior counselor to help with the dog's behavior challenges?*(If yes, please describe below) Yes No Describe:How does the dog react when you or a family member walks nearby while the dog is eating?*Fine, no reactionShows teethGrowlsSnapsBitesLungesNever triedHow does the dog react when you or a family member pets dog or touches the food bowl while dog is eating?*Fine, no reactionShows teethGrowlsSnapsBitesLungesNever triedHow does the dog react when you or a family member touches a toy in dog's mouth?*Fine, no reactionShows teethGrowlsSnapsBitesLungesNever triedHow does the dog react when you or a family member touches a bone, rawhide, pig's ear or similar item while chewing?*Fine, no reactionShows teethGrowlsSnapsBitesLungesNever triedHow does the dog react when you or a family member touches a stolen object (food, tissue, shoe, sock, etc.)?*Fine, no reactionShows teethGrowlsSnapsBitesLungesNever triedHow does the dog react when you or a family member pets or moves dog while sleeping?*Fine, no reactionShows teethGrowlsSnapsBitesLungesNever triedHow does the dog react when you or a family member pushes or pulls dog off of furniture?*Fine, no reactionShows teethGrowlsSnapsBitesLungesNever triedCan another dog take a toy away or go near food?*(If no, please describe below) Yes No Don't know Describe:Has the dog ever growled or snapped at humans?*(If yes, please describe how often and under what circumstances below) Yes No Describe:How was the behavior corrected/managed?Has the dog ever bitten a human?*(If yes, please describe when and under what circumstances below) Yes No Describe:Has the dog ever bitten another dog or cat?*(If yes, please describe circumstances below) Yes No Describe:Does the dog show any discomfort when being hugged?*(If yes, please describe below) Yes No Describe:Does the dog show any discomfort when being restrained (e.g. during a veterinary exam, etc.)?*(If yes, please describe below) Yes No Describe: Personality/TemperamentHow would you describe the dog's general disposition?*Overall, what are the dog's good points?*Overall, what are the dog's bad points?*What does the dog like?*What does the dog dislike?*What are the dog's favorite toys/games?Does the dog like to swim?*(If yes, please describe below [location, duration, etc.]) Yes No Don't Know Describe:Dog's Fears:*(Please check all the apply and use the space below to describe the behavior exhibited) Thunderstorms Fireworks Vacuum Cleaner Strangers New Places Vet's Office Other (describe below) None Describe: Feeding/Grooming InformationTypical appetite:* Excellent Good Fair Poor Ever fed table scraps?* Yes No Groomed by: Owner Groomer Not groomed Grooming frequency: Has the dog ever growled, snapped, or bitten while being groomed?*(If yes, please describe below) Yes No N/A (never groomed) Describe:Please indicate your dog's reaction to brushing:*EnjoysToleratesAfraidGrowlsSnaps/bitesNever donePlease indicate your dog's reaction to bathing:*EnjoysToleratesAfraidGrowlsSnaps/bitesNever donePlease indicate your dog's reaction to nail trimming:*EnjoysToleratesAfraidGrowlsSnaps/bitesNever donePlease indicate your dog's reaction to ear cleaning:*EnjoysToleratesAfraidGrowlsSnaps/bitesNever donePlease indicate your dog's reaction to tail contact:*EnjoysToleratesAfraidGrowlsSnaps/bitesNever doneWhen petting/grooming, is there anywhere the dog does not like to be touched?*(If yes, please describe areas and reaction below): Yes No Describe: Health InformationPast/Present Medical Conditions*Please check any the dog has/had and use the space below to note the date and to make any comments. Ear infections Itchy skin/hot spots Allergies Arthritis/hip dysplasia/stiffness Seizures Gastrointestinal problems Urinary tract problems Low thyroid Heart disease Cancer Other (please describe in the space below) Describe:Is the dog currently on any medications/supplements?*(If yes, please describe below.) Yes No Describe: To the best of your knowledge, has the dog been exposed to sick dogs or rabid animals in the last 30 days?*(If yes, please describe below.) Yes No Describe: To the best of your knowledge, has the dog shown any signs of contagious illness (cough, fever, lethargy, sneezing, runny nose, etc.) in the last 30 days?*(If yes, please describe below.) Yes No Describe: Is the dog currently on heartworm preventative?* Yes No If so, when is he/she due? MM slash DD slash YYYY Does the dog see the veterinarian on a regular basis?* Yes No Date of last vet visit? MM slash DD slash YYYY General behavior during vet visits:No problemTimid/afraidUncomfortable but toleratesRequires muzzleVeterinarian/Animal Hospital Name Vet/Animal Hospital Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Vet/Animal Hospital Phone Other Health Notes and Additional InformationPlease list any other information that may be helpful for us to know about the dog in order to match it with the best possible home.Also, include any information you may know about a previous owner (if applicable).Terms & Conditions* I have read and agree to the terms and conditions of surrender Owner Digital Signature*I understand that entering my name as a digital signature indicates my understanding of all contents and terms/conditions of this form. Co-Owner Digital Signature (if applicable)I understand that entering my name as a digital signature indicates my understanding of all contents and terms/conditions of this form. Date* MM slash DD slash YYYY Owner Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner Phone*Owner Email CAPTCHA Δ
