Stray &#038; Surrender Dog Application

Email
This field is for validation purposes and should be left unchanged.
First Name*
Last Name*
eMail Address*
eMail Address Confirm eMail Address
Street Address*
Suite or Unit Number
City*
State*
ZIP*
Country
- Phone*
History
This field is hidden when viewing the form
Dog Default Status: Submitted
- Are you the legal owner of the dog?*
  - Yes
  - No
- Please Explain*
- Are you the only owner of the dog?
  - Yes
  - No
- Please Provide Other Owner's Name:
- Other Owner's Phone #
When Did You Get The Dog? (approximate if necessary)
Month
Day
Year
How Long Have You Had This Dog?
- How Was The Dog Obtained?*
- Please Explain
- Breeder's Name (if Known)
- Have They Been Notified?
  - Yes
  - No
- Why Not?
- Owner of Dog's Sire (If Known)
- Why Are You Giving Up The Dog?*
- Please Explain
- Please Explain The Behavior Issues
- Please Explain The Health Issues
- Please Explain Care Needed
- How Many Homes Has This Dog Had?
Veterinarian Information
Do You Have a Veterinarian?
- Yes
- No
Name of Clinic
Name of Vet
Street Address
Suite or Unit Number
City
State
ZIP
Phone

- Dog's Name*
- Dog's Registered Name (If Purebred)
- Dog's Registration Number (If Known)
- Primary Breed*
- Breed Name
- Secondary Breed
- Breed Name
- Primary Color*
- Which Color?*
- Secondary Color
- Which Color?*
Gender*
- Male
- Female
Dog's Date of Birth (If Known)
Month
Day
Year
This field is hidden when viewing the form
Weight
This field is hidden when viewing the form
Energy Level*
- Good With Kids?
- Good With Dogs?
- Please Explain*
- Good With Cats?
- Good With Livestock?
- This field is hidden when viewing the form
  Good With Small Animals?
This field is hidden when viewing the form
Is Dog Trained?
- Are There Any Special Needs?
  - Yes
  - No
- What Special Needs?
  Select All That Apply
Description of the Dog
Featured Image
Accepted file types: jpg, jpeg, png, gif.
750 Wide x 750 High in Pixels
Additional Photos of The Dog
Drop files here or

Accepted file types: jpg, gif, png, jpeg, Max. file size: 1 MB, Max. files: 3.
Upload Photos of the Dog (minimum of 3 - include one head shot, one full body) and 750 Wide x 750 High in Pixels

Dog & People
- Is Dog A One Person Dog?
- Does Dog Like Men?
- Please Explain*
- Please Explain*
- Does Dog Like Women?
- Please Explain*
- Please Explain*
- This field is hidden when viewing the form
  Does Dog Prefer Men?
- This field is hidden when viewing the form
  Please Explain*
This field is hidden when viewing the form
Does Dog Prefer Women?
This field is hidden when viewing the form
Please Explain*
This field is hidden when viewing the form
Does Dog Jump On People?
This field is hidden when viewing the form
Is Dog Friendly With Strangers?
This field is hidden when viewing the form
Is Dog Good With Other Animals?
This field is hidden when viewing the form
Is Dog Good With Kids?
This field is hidden when viewing the form
Does Dog Like Kids Under 6?
This field is hidden when viewing the form
Does Dog Like Kids 6-10?
This field is hidden when viewing the form
Does Dog Like Kids Over 10?
Dog's Temperament
Select All That Apply
How Are Dog's Social Skills?
Select All That Apply
This field is hidden when viewing the form
Training
This field is hidden when viewing the form
Does Dog Know Basic Commands?
Select All That Apply
This field is hidden when viewing the form
Is Dog Obedience Trained?
This field is hidden when viewing the form
Is Dog House Trained?
This field is hidden when viewing the form
Is Dog Crate Trained?
This field is hidden when viewing the form
Is Dog Leash Trained?
This field is hidden when viewing the form
How Does Dog React on Walks?
Select All That Apply
This field is hidden when viewing the form
Does Dog Know How To Use A Doggie Door?
This field is hidden when viewing the form
Does Dog Have Occasional Accidents?
This field is hidden when viewing the form
Does Dog Tear/Chew Furniture Or Carpet?
This field is hidden when viewing the form
Can Dog Be Left Uncrated?
This field is hidden when viewing the form
Does Dog Dig?
This field is hidden when viewing the form
Does Dog Know How To Swim?
This field is hidden when viewing the form
Does Dog Jump Fences?
This field is hidden when viewing the form
Does Dog Escape?
This field is hidden when viewing the form
Does Dog Ride Well In The Car?
Barking
- Does Dog Bark At Noises?
- Does Dog Bark At Someone At The Door?
- Does Dog Bark Excessively?
This field is hidden when viewing the form
Fear & Agression
This field is hidden when viewing the form
Does Dog Exhibit Submissive Behavior?
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Does Dog Exhibit Aggressive Behavior?
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Does Dog Guard Food?
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Does Dog Guard Other Resources (Toys, People, etc.)?
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Is Dog Shy?
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Is Dog Fearful Of Strange Noises/Storms?
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Has Dog Ever Bitten Anyone?
This field is hidden when viewing the form
Please Explain*
This field is hidden when viewing the form
Has Dog Otherwise Attacked Anyone?
This field is hidden when viewing the form
Please Explain*
This field is hidden when viewing the form
Has Dog Attacked Another Animal (Dog, Cat or Other)?
This field is hidden when viewing the form
Please Explain*
This field is hidden when viewing the form
Is there anything else you would like to let us know about the dog's disposition?

This field is hidden when viewing the form
Medical: MicroChip Information
This field is hidden when viewing the form
Is Dog MicroChipped
This field is hidden when viewing the form
Are you prepared to transfer registration to {RescueName} on or prior to the surrender of the dog?
- Yes
- No
This field is hidden when viewing the form
MicroChip Company (If Known)?
This field is hidden when viewing the form
Other Company
This field is hidden when viewing the form
MicroChip Number (If Known)?
This field is hidden when viewing the form
Does Dog Have a Tattoo?
This field is hidden when viewing the form
Please Upload Photo*
Drop files here or

Accepted file types: jpg, gif, png, jpeg, Max. file size: 5 MB, Max. files: 3.
This field is hidden when viewing the form
Please Describe*
This field is hidden when viewing the form
Medical: Medical Conditions
This field is hidden when viewing the form
Add Current Medical Conditions (N Number)
This field is hidden when viewing the form
Add Past Medical Conditions (N Number)
Medical: Status
- Is Dog Spayed Or Neutered?
  - Yes
  - No
- Date:
  Month
  Day
  Year
- Expected Date
  Month
  Day
  Year
- Please Explain Why Not*
This field is hidden when viewing the form
Medical: Dental Conditions
This field is hidden when viewing the form
Add Current Dental Conditions (N Number)
This field is hidden when viewing the form
Add Past Dental Conditions (N Number)
This field is hidden when viewing the form
Medical: Known Allergies
This field is hidden when viewing the form
Add Allergies (N Number)
This field is hidden when viewing the form
Medical: Medicines
This field is hidden when viewing the form
Add Medications (N Number)

History

Veterinarian Information

Eating

Sleeping

Grooming

Dog & People

Training

Barking

Fear & Agression

Medical: MicroChip Information

Medical: Medical Conditions

Medical: Status

Medical: Dental Conditions

Medical: Known Allergies

Medical: Medicines

Notes

Hours of Operation

Phone Hours