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Owner Surrender of Pet Form
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Indicates required field
Owner
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First
Last
Name of Animal
*
Description of the animal, color, age, weight, etc.
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I hereby voluntarily relinquish all claims and ownership of said animal to the organization known as Back Roads Animal Rescue, Inc. ("Rescue") and members thereof. I cannot reclaim this dog once the dog is in the possession of Rescue and understand that this animal will be spayed or neutered, if needed. I agree to give up the dog’s American Kennel Club registration papers and all medical records available. Neither Rescue nor members thereof shall be held responsible for actions of the adoptive or foster family and/or dog. I certify that this dog is not vicious and has never shown signs of aggression towards human beings, and certify that this dog has never bitten anyone.
Date
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Email
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Please answer the following to the best of your ability:
1. Name, address and telephone number of the breeder or person you (the owner) got the dog from:
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2. How long have you owned this dog?
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3. Why is the dog being given up?
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4. What is the name and address of the veterinarian who last treated and vaccinated this dog?
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The following questions will be of help to the person who will adopt your dog. If there is anything you would like to add that may make your pet's adjustment to a new home easier, please feel free to share that information. We want to make the adoption a success and will work hard to have happy owners and happy dogs.
5. Choose the words that best describe your dog:
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friendly
protective
shy
noisy
quiet
active
playful
nervous
smart
affectionate
aggressive
obedient
calm
6. Is the dog current on vaccinations?
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Yes
No
Please list dates of vaccinations.
Rabies, DHLPP, Bordetella, Lyme, Any others?
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7. Date of last heartworm test: Neg Pos
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Is the dog on heartworm preventative?
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Yes
No
Type of heartworm medication dog is taking?
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Date of last pill?
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8. Is the dog spayed or neutered?
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Yes
No
9. Has the dog been previously bred?
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Yes
No
10. Date of last fecal exam for parasites:
Results:
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If positive, was the dog treated?
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Yes
No
11. Medications the dog is taking?
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12. Is the dog housebroken?
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Yes
No
Partly
If partly please describe when accidents occur:
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13. Are there any behavior problems?
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Yes
No
If so, what are they?
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14. Does the dog get along with other dogs?
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Yes
No
Cats?
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Yes
No
Other animals?
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Yes
No
15. Does the dog like children?
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Yes
No
Are there children in the home?
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Yes
No
What are their ages?
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16. What BRAND of dog food is the dog fed?
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Canned
Dry
Semi-Moist
Combination
How much is the dog fed?
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How often is the dog fed?
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Are there any specific feeding instructions you wish to share with the new owner?
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17. Where does the dog sleep?
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18. Is the dog allowed on the furniture?
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Yes
No
19. Is the dog crate trained?
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Yes
No
20. Where did you keep the dog during the day?
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At night?
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21. How does the dog react to being left alone?
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22. Is it afraid of anything in particular? (thunder, men, brooms, uniforms, etc.)
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23. Describe any training the dog has had, or tricks it has learned:
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24. Does the dog have any health problems?
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Yes
No
If yes, please describe:
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25. Does the dog like riding in the car?
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Yes
No
26. What is the dog's favorite toy or play thing?
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Favorite things to do?
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27. What does the dog like?
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28. What does the dog dislike?
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29. Does the dog jump kiddie gates or fences?
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Yes
No
If yes, please indicate how high the dog jumps:
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30. Is the dog a digger?
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Yes
No
31. Is there anything else you can share that is special, unusual, or endearing about your dog that would help the new owner?
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32. Are there any things you think a new owner needs to know?
*
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About
Surrender
Donate
Volunteer
Foster
Apply to Volunteer
Adopt
Adoption App
Blog
Contact
TNR
Be Involved
Fence Project
Forms
