Canine Surrender Form

The information you provide on this form will help us match your dog with an appropriate new home.

If you have any problems submitting this form online, please contact us or download the form to send via email or U.S. mail.


Owner

Street Address
City      State      Zip Code

Day Phone      Evening Phone
Mobile Phone

Email

Dog's Name      Male   Female
Breed      Color & Markings
Age      Weight (lbs.)      Spayed/Neutered?   Yes   No

Current Veterinarian
Street Address
City      State      Zip Code
Phone

Date of last vaccinations:
Rabies      Parvo/Distemper      Other
Explain

Date of last visit to veterinarian
For?

Does your dog have any old/new injuries or health issues?   Yes   No
If yes, please explain

Is your dog taking medication or supplements?   Yes   No
List
Reason

Are you this dog's first owner?   Yes   No
Explain where and why you got this dog

Does your dog get along with (check all that apply)
Children   Male Dogs   Female Dogs   Cats   Livestock

Has your dog ever growled at you or anyone?   Yes   No
Please explain

Has your dog ever bitten?   Yes   No
Who was bitten (e.g. child, friend)?
Please explain

Is your dog possessive of food or toys?   Yes   No
How does he/she react?

Has your dog ever been in a dog fight that caused injuries serious enough to send either to the vet?   Yes   No
Please explain

Where does your dog stay at night? Be specific.
Where does your dog stay during the day?
How long is the dog alone during day?

Is your dog house trained?   Yes   No
Is your dog crate trained?   Yes   No
Is your dog leash trained?   Yes   No

Has the dog had any obedience training?   Yes   No
What commands does he/she know?

Does your dog jump/climb fences?   Yes   No      Bark a lot?   Yes   No

Describe your dog's personality:


Please explain in detail why you wish to surrender your dog:


SURRENDER FEE: Jazzin Around Rescue does not charge a surrender fee, however, does ask that you make a donation in any amount that you can or donate food, toys, dog houses, etc. Jazzin Around Rescue will do its best to find your dog a forever home. In the meantime, Jazzin Around Rescue will be responsible for his or her care and medical treatment. Jazzin Around Rescue does not receive any type of funding and exists solely on donations and personal funds.

You agree that you, your spouse, and /or any co-owner of the dog described on this form are irrevocably transferring and relinquishing to Jazzin Around Rescue legal ownership of said dog on the date of surrender/acceptance. This gives Jazzin Around Rescue complete authority to take whatever actions in our sole judgment are necessary and in the best interest of the dog.

Signature      Date


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