The Sanctuary...

Dog Surrender Application

Please provide as much information as possible to the following questions. This will help us to provide for the dog, and place him or her in the most appropriate home. Your answers to these questions will not determine whether or not we will accept the dog. Please answer honestly as this will help us properly place the dog.

To download a pdf version of this form and fill it out by hand click here

General Information

* Name of Dog:

Dog's Date of Birth:

* Dog's Gender:

* Dog's Breed:

* Where did you obtain the dog?

If other, explain:

If the dog was a stray, where was it picked up?

* Did you contact Animal Control?

* How long have you had the dog?

Health and Well-Being

Please note that we will need a copy of all veterinary records for the dog.

Please describe the condition and health of the dog:

Has the dog been spayed/neutered?

* Has the dog received vaccinations?

If yes, which vaccinations were last received?

On what date were they given?

* Has the dog been heartworm tested?

If yes, when was it tested?

What were the results?

* Is the dog currently on a monthly heartworm preventative?

How does the dog act when at the veterinarian's office?

Personality and Behavior

In your own words, describe the personality of the dog.:

What is your dog afraid of or uncomfortable with?

What, if any, body parts is the dog sensitive about being handled?

Does the dog run away?

Does the dog Bark?

Does the dog bite?

If the dog misbehaves what do you do?

	Yell at it
	Spank it
	Put in a separate area
	Ignore it
	Other

What is the best quality of the dog?

What is the worst quality of the dog?

Has the dog had problems with any of the following?

	Digging Holes
	Chewing
	Digging Under the Fence
	Climbing or jumping over the fence
	Marking indoors with urine
	Other

If other, please explain:

Any additional information about the dog's personality or habits that you would like us to know:

Training

What type of training has been used with the dog?

* Have you taken your dog to training classes?

If yes, when?

Where?

* Have you done your own training?

What behaviors has your dog been trained to do (i.e. sit, stay, shake, etc)?

Behavior With Other Animals

* Has the dog lived with other animals?

If yes, who?

What is their behavior towards them?

What does the dog do when it sees cats outside the house?

How does the dog react to other animals when on a leash?

How does the dog react to other animals when off leash?

Has the dog ever fought with other dogs?

Has the dog ever injured other dogs?

Tolerance of People

Describe the dog's behavior with people in the following situations

Visitors in the home:

Visitors on a walk:

Mailperson/delivery person:

You, when the dog is eating:

Other people, when the dog is eating:

Taking a toy away from te dog:

Taking a bone or chewie away from the dog:

When someone knocks on the door/rings doorbell:

When the dog is asked to get off the couch:

When the dog is hugged:

When the dog is reprimanded:

When the dog is bathed:

When the dog's nails are clipped or ears are cleaned:

Tolerance of/experience with children

* Has the dog lived with children?

If yes, what ages?

What genders:

How does the dog behave with visiting children?

How does the dog react in the following situations involving children

Screaming/crying:

Touching/petting:

Pulling on dog's tail/ears/fur:

When a child is running around the house:

When a child is on a bike:

When a child hugs them:

When a child runs towards them:

When you pick up the child:

Aggression Towards People

Has the dog ever done any of the following? If yes please give a description of the behavior.

* Growled:

If yes, explain:

* Snarled:

If yes, explain:

* Snapped:

If yes, explain:

* Nipped:

If yes, explain:

* Bitten:

If yes, explain:

Routine

How often do you let the dog out to go to the bathroom?

At what times?

* Is the dog housetrainied?

How often does the dog have accidents in the house?

Does the dog have accidents when left alone or when you are home?

* What kind of accidents does the dog have?

What kind of food do you feed the dog?

How often do you feed it?

What kinds of toys does the dog like to play with?

What kind of games do you play with the dog?

How often do you walk/exercise the dog?

How is the dog with walking on a leash?

Have you taken the dog to doggy daycare? If so which one?

Have you taken the dog to a dog park?

* The dog has been in a fenced-in yard:

* the dog has been in a dog run:

* the dog has been outside free-roaming/not tied up or contained in a fence:

* The dog has used a dog house:

* The dog has been in the house:

* The dog has been in an indoor crate:

* Has the dog been allowed on the furniture?

If yes, where?

Reason for Surrendering

* Why are you surrendering the dog?

* We appreciate your commintment to our purpose with the release of this/these animal(s). With each animal surrendered, HEA incurs additional expenses to provide proper care for the animal. Please select the amount you would like to donate:

If other please designate the amount:

* Your Name:

Organization (if applicable):

* Street Address:

* City:

* State/Province/Province:

* Zip Code:

Home Phone:

Work Phone:

Time you can be reached:

Fax Number:

* Email Address:

* Digital Signature:

* Initials:

* Date: