Kismutt Small Dog Rescue Surrender Form

Date:

I, _______________________________ (owner), being the owner of _____________________________(name of dog) being a _______________________________________________(description of the dog) hereby voluntarily relinquish all claims and ownership of said dog to the organization known as Kismutt Small Dog Rescue ( hereinafter known as 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 and receive medical attention, if needed. I agree to give up the dogs Canadian Kennel Club or American Kennel Club registration papers and all medical records available.  I certify that this dog is not vicious and has never shown signs of aggression towards human beings, and certify that this dog has not bitten anyone within the last ten days. I also understand that if the Rescue deems it necessary, the Rescue has the right to euthanize said dog, if and only if, said dog exhibits insurmountable medical or behavioral issues (such as aggression). (The Rescue would like to stress that euthanization only occurs when absolutely necessary and all other reasonable avenues of behavior modification, training etc, have been exhausted.) Thank you for placing your trust in us. We will endeavour to find this dog a permanent loving home as soon as possible. In the meantime, this dog will be placed in one of our pre-approved foster homes for immediate care.

            Signature:                                            Date:   

            City:                                                     Province/Postal Code:

            E-Mail:                                     Phone:

Please answer the following: 

1.         Name, address and telephone number of the breeder or person you got the dog from:

2.         How long have you owned this dog?

3.         Why is the dog being given up?

4.         What is the name and address of the veterinarian who last treated and vaccinated this dog?

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 with happy dogs.  Please be honest about any behavioral challenges this dog has.  By being honest, we have a greater success in finding the dog an appropriate home.
 

5.         Circle or mark with an *asterix* the adjectives that best describe your dog:

           friendly      protective          shy        noisy       quiet       active       playful nervous             smart        affectionate     aggressive      obedient         calm

6.         Is the dog current on vaccinations? Please list dates of vaccinations.

Rabies:

DHLPP:

Bordatella:

Any others? Please list.

7.         Date of last heartworm test:      Neg:     Pos:

Is the dog on heartworm preventative? (*please mark with asterix*) Yes    No

Brand of heartworm medication dog is taking?

Date of last pill?

8.         Is the dog spayed or neutered?

9.         Date of last fecal exam for parasites

Results

If positive, was the dog treated?

10.       Medications the dog is taking and for what conditions?

11.       Is the dog housebroken? (mark with asterix*) Yes   No    Partly  

If partly, please describe when accidents occur:

12.       Are there any behavior problems, if so what are they?

13.       Does the dog get along with other dogs?

            Cats?

Other animals?

14.       Does the dog like children?

Are there children in the home?

What are their ages?

15.       What BRAND of dog food is the dog fed?

            (mark with asterix*)

Canned___ Dry___Semi-Moist___ or a combination_

How much is the dog fed?_____________

How often is the dog fed?__________

Are there any specific feeding instructions you wish to share with the new owner?

16.       Where does the dog sleep?

17.       Is the dog allowed on the furniture?

18.       Is the dog crate trained?

19.       Where did you keep the dog during the day?

            At night?

20.       How does the dog react to being left alone?

21.       Is it afraid of anything in particular? (thunder, men, brooms, etc.)

22.       Describe any training the dog has had, or tricks it has learned:

23.       Does the dog have any health problems? Yes ___ No ___

If yes, please describe:

24.       Does the dog like riding in the car?

25.       What is the dog’s favorite toy or play thing?

            Favorite pastime?

26.      Does the dog like swimming?

27.      How does the dog react to  being bathed?

28.       What does the dog like?  

29.       What does the dog dislike?

30.       Does the dog jump kiddie gates or fences?

If yes, please indicate how high the dog jumps?

31.       Is the dog a digger? (mark with asterix*) Yes ____ No ____

32.       Is the dog a chewer or is the dog destructive? (examples: chewing furniture, shoes, wood, household articles ....  etc. etc.)

33.       How is the dog off-leash? Is the dog reliable off-leash?

34.       Is there anything else you can share that is special, unusual, or endearing about your dog that would help the new owner?

35.       Are there things you think a new owner ought to be aware of?

Please return form to:

Kim Thomas                                                             

RR4 St. Marys-882702                                              

Ontario, N4X 1C7                                                    

Or email to kismutt@sympatico.ca

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