First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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County

Country*

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

I hereby certify that I am the rightful owner/keeper/caretaker/custodian of the animal who is the subject of this Animal Surrender Form, hereinafter referred to as “the animal.” PRINT NAME BELOW.*

I hereby surrender any and all property rights to the animal. I certify that no other person has a right of property to the animal. PRINT NAME BELOW.*

I hereby certify that the animal has / has not bitten or scratched a human or another animal within the past TEN days. Choose option below! Incidents earlier than this are asked about further in the application

If the animal has bitten or scratched a human or other animal in the last TEN days, please provide full detailed information below.

If the animal being surrendered has bitten or scratched a human or other animal in the last TEN days please provide information of whom and how this was reported, please provide any case or references numbers, including the time and date of report.

I understand that once I relinquish the animal, the animal will not be available to be returned. PRINT NAME BELOW.*

I further certify that I have read and understand the terms of this Animal Surrender Form. PRINT NAME BELOW.*

Brief Reason for needing to surrender the animal - more detailed questions are throughout the form.*

Have you reached out to a veterinarian or discussed the option of euthanasia of this animal?

Please provide name and number of veterinarian and the context of the discussion.*

Where did you originally get him/her from?*

What date did you Adopt / Purchase / Rescue him/her?*

Please provide information on the animal you are requesting to surrender

Name of Animal*

Species of Animal*

Microchip Number*

Microchip Company*

Has the animal been spayed / neutered?

Date of Birth *

Animal Colour*

What is the current weight of the animal?*

In order to surrender any animal, you must contact the animals veterinarian and tell them of your decision to surrender the animal to GaDaH and ask them to email the complete PATIENT HISTORY to giveadogahome.maine@gmail.com. You will NOT be able to surrender the animal until that medical history has been received. It is advised that you pause this surrender form process and call the veterinarian now so that you do not forget. PRINT NAME TO ACKNOWLEDGE UNDERSTANDING AND AGREEMENT*

Please provide contact information of veterinarian of whom the animal has treated by.*

Veterinarians Phone Number*

Please provide your Veterinarians Email - if you do not know this, you can call them to get it!*

Please provide the date of the animals last RABIES vaccination.*

Please provide the date the Rabies Booster Vaccine is needed.*

Other vaccinations animal is current on.

CATS ONLY - Has the cat been tested for FeLV and FIV ?*

CATS ONLY - Date & Results of FIV/FELv Test*

Date of the last heartworm/tick disease (4DX) test*

Has the animal tested positive for heartworm, any tick disease or any other disease or illness.

List disease and date tested positive.

Does the animal have any medical issues - injury, disease, allergies that you are aware of? If so, please provide information, symptoms, when diagnosed, treatment, ongoing care ect.*

Does he/she have any medical issues/concerns? *

Other than spay/neuter has he/she had any surgical procedures? *

Other than monthly preventatives is he/she on any kind of medication? *

What Flea - Tick prevention has the animal been given?*

When did the animal receive it's last dose of Flea-Tick prevention and how often was it given?*

Which monthly Heartworm Prevention was given whilst in your care?*

What date was the last monthly heartworm preventative given and how often was it given?*

Does the animal need a special diet?

What food do you currently feed? *

What is the feeding schedule? *

How long have you been feeding this particular food? *

Does he/she have any favourite treats? *

How is he/she with dogs? *

How is he/she with cats? *

How is he/she with small animals? *

How is he/she with livestock - chickens, goats, horses, or other animals*

How is he/she with Men*

How is he/she with Women?*

How is he/she with Teenagers - males / females?*

How is he/she with Small Children / Babies*

How is he/she with strangers in the home? *

How is he/she with workmen, mail and parcel delivery in and around the property?*

Does he/she have any of the following behavioral issues?  lease explain each issue. (Please be honest, it will let us know what things we should work on with the dog)

Separation or Other Anxiety*

Chewing:*

Destroying/damaging furniture/property*

Excessive noise*

Digging*

Inappropriate Urinating*

Begging*

Fear of loud noises/objects*

Play Mouthing*

Chasing (cars, animals, people, etc): *

Protective of house, family, etc*

Jumping Up*

What did you do to work on any/correct any of the above issues? *

Has he/she ever bitten anyone? If yes please provide date: *

Was the incident reported to the police/animal control? If yes please provide incident / reference number and date and location.*

What was the circumstances of the bite? *

What was the level / type of bite from Dr. Ian Dunbar's Dog Bite Scale below?

Aggression of any type: (Human, animal, toy, food etc.): *

What did you do to address the aggression? *

Did you reach out to a professional trainer, behaviour expert, veterinarian or other experienced person? Please provide steps taken, sessions and outcome.*

Provide the Professionals contact information of whom you worked with.*

Please provide his/her daily routine*

Is he/she house-trained? *

If not house-trained - what steps did you take to work on the issue?*

Does he/she know how to use a dog-door? *

How do they let you know they need to go outside? *

Where does he/she sleep? *

Where does he/she go when you are not home?*

What toys does he/she have? *

What is their favourite toys/games? *

What is his/her activity level? *

Do you go to dog parks? If so, how does he/she interact? *

How do you provide exercise? *

How do you provide mental stimulation? *

Why do you feel the need to request this surrender?*

Are you donating anything with the animal to help his/her transition to the rescue (Crate, toys, bowls, leash, collar etc.)? *

Anything else that would be helpful for us to know? *

Is it ok for potential adopters that have been screened by the rescue, to contact you with any questions within the first few weeks of surrendering him/her? If so, please provide how you would like to be contacted. We understand if you do not want to be contacted.*

I certify that everyone in the household knows and is in agreement to this animal surrender to Give a Dog a Home, German Shepherd Dog Rescue and that all information provided is accurate and true. Print Name to acknowledge and certify.*