Dog Surrender Profile By completing this form you are giving GAWS a written consent to relinquish all rights to your companion animal. To ensure the best possible outcome for your pet, please complete this form thoroughly. This will assist our staff when conducting health and behavioural assessments. Your honest answers are necessary to ensure that we can find the most suitable pathway for your pet. If your dog has a history of antisocial behaviour towards humans or other animals, please speak to a Customer Service Representative. OWNER DETAILS Mr / Mrs / Miss / Ms Given Name: Surname: Address: Suburb: Ph: Postcode: Email: DOG DETAILS Dog name: Breed: Age: Colour: Sex: Male Female Desexed: Yes No Unsure Microchipped: Yes No Microchip Number: Is your dog registered with Council? Yes No Unsure Where did you get your dog? How old was the dog when you got him / her? Are you surrendering your dog because you cannot afford the vet treatment? Yes No If no, why are you surrendering your dog?
LIFESTYLE & HOME LIFE Is your dog allowed inside? Yes No Sometimes Is your dog allowed outside? Yes No Sometimes Where does your dog prefer to spend most of its time? Indoors Outdoors When no one is home where is your dog kept? What does your dog do as you leave the house? What does your dog do when left alone? What does your dog do when you return home? Where does your dog sleep at night? How much time does your dog spend alone? Is your dog house trained? Yes No Does your dog follow you from room to room when you are home? Yes No Sometimes Do you have any other dogs? Yes No Cats? Yes No Other pets? How does your dog interact with the other pets? Which pet arrived first?
SOCIAL INTERACTIONS How would you describe your household? Busy Quiet In between How many adults live in your household? Do any children live with the dog? Yes No Ages? If yes, does the dog : Tolerate them Ignore them Walk away Hide from How does the dog interact with the kids? Does your dog have any bad behaviour? Digging Chewing Aggression of any type Anxiety Escaping Fence Jumping / Digging to get out Has your dog had any training? Yes No What type of training? Basic training Obedience School What commands does your dog know? For example: sit, stay, recall, tricks
How does your dog react to people / strangers come to the house? Excited / Playful Ignores Growls / Barks Hides How long does it take for him / her to calm down? Does your dog have access to visitors? Yes No Does your dog need to be restrained or is he / she free to interact? Yes No Is your dog happy to be touched / handled by visitors / strangers? Yes No If no, how does your dog react? Are there any parts of the body he / she do not like being touched by strangers / visitors? Yes No If yes, what body part? TICK ALL THAT APPLY How does your dog react to Poultry / Livestock? Friendly Barks Growls Snaps at Avoids Not interested Hides Other How does your dog react to Fireworks / Thunderstorms? No reaction Barks Hides Has anxiety runs away Other How does your dog travel in the car? Great Barks at outsiders sleeps Car Sick Avoids Hides Other How does your dog react to other dogs off lead? Playful Barks Growls Snaps at Avoids Not interested Hides Other How does your dog react to other dogs on lead? Playful Barks Growls Snaps at Avoids Not interested Hides Other How does your dog react to cats? Friendly Barks Growls Snaps at Avoids Not interested Hides Other
BEHAVIOUR & TEMPERAMENT How active is your dog? Very Moderately Not very Unsure How playful is your dog? Very Moderately Not very Unsure How affectionate is your dog? Very Moderately Not very Unsure Does your dog like to hunt or chase prey? Very Moderately Not very Unsure Does your dog like to be patted / touched Very Moderately Not very Unsure Is your dog outgoing and interactive? Very Moderately Not very Unsure Is your dog shy and likes to be left alone? Very Moderately Not very Unsure Does your dog enjoy being picked up / handled Very Moderately Not very Unsure Has your dog ever bitten anyone, even whilst playing? Yes No If yes, details as to what degree the bite was: SURRENDER CONDITIONS 1. I am the owner of the above mentioned animal and declare that no other person has any property interest therein. 2. I hereby surrender all rights, title and interest in the said animal to the GEELONG ANIMAL WELFARE SOCIETY and agree that the said animal will become the sole and absolute property of the Society which is hereby authorised to hold, sell, destroy or dispose of this animal as the Society s discretion. 3. I hereby agree to indemnify the Society and keep the Society so indemnified against all claims (if any), costs and expenses whatsoever arising from any action by any person claiming interest contrary to that expression in Paragraph on hereof. By signing below, I certify that the information provided is accurate and truthful to the best of my knowledge. Name : Date: Signature: