Stray &#038; Surrender Dog Application

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

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

Accepted file types: jpg, gif, png, jpeg, Max. file size: 5 MB, Max. files: 3.
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Please Describe*
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Medical: Medical Conditions
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Add Current Medical Conditions (N Number)
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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*
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Medical: Dental Conditions
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Add Current Dental Conditions (N Number)
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Add Past Dental Conditions (N Number)
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Medical: Known Allergies
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Add Allergies (N Number)
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Medical: Medicines
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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