Petstablished | Manage your Animal Welfare Organization (AWO) with our easy-to-use software.

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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

* GenderMaleFemale

Country

*State/Province

Date of Birth

* Month

* Day

* Year

About the Dog

Dog's Name

Sex

FemaleMale

Age

Weight (Approximate)

Primary/Secondary Breed

Coloring and any distinctive marks

Surrender Situation

It is illegal for us to accept and adopt out a dog with a bite history.
Surrendered dogs must get along with other dogs.
We are unable to accept Pitt Bulls

Has your dog ever bitten another animal and/or a person?

YesNo

Why are you surrendering this dog?

What is your relationship to the dog's owner.

If you are not the current owner, please let us know how you have permission to surrender the dog, e.g., you are the family member or friend designated to do this.

Is this dog part of a bonded pair?

If your dog is part of a bonded pair, please complete a form for each dog. VERY IMPORTANT: If your dog is part of a bonded pair, can he/she be separated from their sibling or are they better adopted together?

YesNo

What actions have been taken to find the dog a new home?

How many owners has the dog had?

How long have you or the most recent owner had the dog?

Has the dog been an indoor pet?

YesNo

Do you have a deadline for when you must physically surrender the dog or are you able to keep (foster) the dog until a suitable home is found.

While we try to help all that we can, sometimes we must wait for a foster home to open up so we may not be able to meet firm deadlines.

This is not a requirement for us to take your dog. We ask because it helps our rescue. Are you able to help defray our cost (in full or in part, even a small part) in preparing your dog for adoption, including bringing them up to date on any pending vaccinations, conducting a heartworm test, performing bloodwork, and/or spaying or neutering them if this has not been done yes? This is our standard medical protocol for any dog that is surrendered to us.

YesNo

Dog's Behavior

To get an idea of the dogs personality, obediance and who it gets along with

Is your dog housebroken?

If not completely housebroken, please describe in as much and as honest detail as you can what his/her potty habit situation is. We do not reject animals solely based on this issue but our future fosters and/or adopters need to know. This helps ensure a good fit for your dog.

How long can the dog go between potty breaks, without having an accident?

Of course this is an estimate but basically we want to know how frequently the dog has to go out to avoid accidents.

For how long can your dog be alone without having fear and/or anxiety, or without barking or whining?

We use this information to help place the dog with the appropriate foster and permanent home.

Does the dog get along with cats?

YesNoI don't know

Does the dog get along with other dogs?

YesNoI don't know

Does the dog get along with children?

YesNoI don't know

If the dog has or has not gotten along with children, please indicate age ranges.

babies, under 5 years, 6-10 years, 10-13 years, 14 years and above

Does the dog have a preference for certain people?

Choose all that apply

Prefers FemalesPrefers MalesLikes Females and MalesIs slow to warm upDoesn't like strangers

How would you describe the dog's personality?

How does the dog like to play?

What are the dog's favorite toys, games?

What percent of the time would you say that the dog is obedient:

What do you think would be an ideal home for this dog?

What energy level would you rate the dog?

Couch PotatoMedium EnergyAthletic Hyper as heck most of the time!

Does the dog indicate a need to go out?

In what ways does the dog let you know: it barks by the door, whines etc

Is the dog groomed periodically?

Does the dog enjoy baths and grooming?

Is your dog able to walk on a leash without pulling or barking?

Does your dog bark or pull to get near other dogs, animals or people when you have them outside? Under which circumstances does this occur?

Please list the commands your dog obeys.

Diet

What type of food is the dog accustomed to eating? Please be as specific as you can (brand, dry, wet).

What is your dog's feeding schedule?

Are there any eating or food issues?

If yes please describe

Health

Has the dog received a heartworm preventative?

Please provide brand, date last given if known.

Has your dog been diagnosed or treated for medical issues/conditions?

Include any surgeries

Veterinarian's Name and Contact Information

Has the dog been received flea and/or a tick preventative?

Please provide brand, date last given if known.

What are your dog's vaccines and dates, if known?

Is the dog spayed or neutered?

YesNoUnsure

Would you be able to have your dog’s medical records emailed to us at karinareyes1014@gmail.com as soon as we accept your dog into our rescue? (All information, including your identification, will be kept confidential and will not be released to the new dog's owners when adopted.)

YesNo

Does the dog have any I.D. (tattoo, microchip)?

Please describe (include microchip number and if the chip is registered, where).

Agreement to Surrender

By typing my name below, I certify that I am prepared to willingly relinquish ownership of the above dog to Citizen Canine Senior Dog Rescue, pending their acceptance (based on foster/adopter availability) of my dog, I certify that I am the owner or designated caregiver of this animal, or that the animal is a stray and the owner is unknown to me. I relinquish and give up all rights and claims to this dog.

I have read and agree to the terms and conditions. By checking this box I am confirming that I am 13 years of age or older.

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Dog Surrender Form

Personal Information

About the Dog

Surrender Situation

Dog's Behavior

Diet

Health

Agreement to Surrender