CANINE SURRENDER AGREEMENT THE FOLLOWING QUESTIONNAIRE PROVIDES US WITH INFORMATION ABOUT THE ANIMAL YOU ARE SURRENDERING. THIS INFORMATION WILL HELP US FIND THE MOST SUITABLE HOME FOR THE ANIMAL AND EFFECTIVELY COUNSEL THE NEW FAMILY. YOUR OPEN AND HONEST ANSWERS ARE VERY MUCH APPRECIATED. I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IS ACCURATE AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE, THAT I AM THE LEGAL OWNER OF THE ANIMAL(S), AND THAT THE ANIMAL(S) HAVE NOT BITTEN ANY PERSON DURING THE LAST 10 DAYS. I HEREBY RELEASE THE ANIMAL(S) INTO THE CUSTODY OF THE SAN ANTONIO HUMANE SOCIETY (SAHS). THE SAHS HAS MY PERMISSION TO USE ITS BEST JUDGEMENT IN THE PLACEMENT OF THE ANIMAL(S). I UNDERSTAND THAT ONCE THE SAHS TAKES CUSTODY OF THE ANIMAL(S) I WILL BE UNABLE TO RECLAIM OWNERSHIP OR ADOPT THE ANIMAL(S) UNLESS EXPRESSLY REQUESTED BY SAHS STAFF. I UNDERSTAND THAT ALTHOUGH THE SAHS STRIVES TO PLACE ALL ADOPTABLE ANIMAL(S) IN HOMES, ANY ANIMAL(S) DETERMINED TO BE UN-ADOPTABLE FOR ANY REASON MAY BE EUTHANIZED. THESE REASONS INCLUDE, BUT ARE NOT LIMITED TO, ILLNESS OR INJURY THAT THE SAHS IS UNABLE TO TREAT AND/OR TEMPERAMENT ISSUES THAT ARE BEYOND REHABILITATION. PRIOR TO EUTHANASIA THE SAHS CAN CONTACT YOU TO RECLAIM THE ANIMAL(S). PLEASE INDICATE BELOW IF YOU WISH TO BE CONTACTED. PLEASE CONTACT ME PRIOR TO EUTHANASIA PLEASE DO NOT CONTACT ME PRIOR TO EUTHANASIA NAME: ADDRESS: DATE: APT. NO.: CITY: STATE/ZIP: PHONE NUMBER(S): 1
SIGNATURE: BASIC INFORMATION DOG S NAME: AGE: BREED: SEX: MALE FEMALE SPAYED NEUTERED INTACT IS THIS DOG MICROCHIPPED? YES NO IS THE MICROCHIP REGISTERED TO YOU? YES NO GENERAL HISTORY 1. WHY ARE YOU SURRENDERING THIS DOG? PLEASE BE AS DETAILED AS POSSIBLE: 2. HOW LONG HAVE YOU HAD THIS DOG? 3. INCLUDING YOURS, HOW MANY HOMES HAS THIS DOG HAD? 4. DID THIS DOG COME FROM ANOTHER RESCUE GROUP OR SHELTER? YES NO IF YES PLEASE NAME ORGANIZATION HERE: 2
PERSONALITY & BEHAVIOR 1. DESCRIBE THIS DOG S ACTIVITY LEVEL: VERY ACTIVE MODERATELY ACTIVE MOSTLY CALM COUCH POTATO 2. WOULD YOU DESCRIBE THE DOG AS LOUD? YES NO 3. PLEASE DESCRIBE THE DOG S LEVEL OF INDEPENDENCE ON THE SCALE BELOW: VERY SOCIAL 1 2 3 4 5 6 7 VERY INDEPENDENT 4. PLEASE DESCRIBE THE DOG S LEVEL OF AFFECTION ON THE SCALE BELOW: VERY AFFECTIONATE 1 2 3 4 5 6 7 NOT AFFECTIONATE 5. PLEASE DESCRIBE THE DOG S LEVEL OF FEARFULLNESS ON THE SCALE BELOW: FEARLESS 1 2 3 4 5 6 7 FEARFUL (SCARED OF EVERYTHING) 6. DOES THE DOG ENJOY PLAYING WITH TOYS? YES NO IF YES, WHAT TYPES OF TOYS? 7. WHEN THE DOG PLAYS DOES IT (CIRCLE ALL THAT APPLY): JUMP GROWL BARK NIP BITE LIGHTLY BITE HARD 8. IS THE DOG ALLOWED ON THE FURNITURE? YES NO 9. WHAT COMMANDS DOES THE DOG KNOW? SIT STAY DOWN COME HEEL SHAKE/GIVE PAW OTHER: 3
10. HAS THE DOG ATTENDED ANY TRAINING CLASSES? YES NO 11. DOES THE DOG KNOW HOW TO WALK ON A LEASH? YES NO 12. HOW MANY HOURS A DAY IS THIS DOG LEFT ALONE? 0-3 HOURS 4-8 HOURS 9-12 HOURS OVER 12 HOURS 13. WHEN THE DOG IS LEFT ALONE DOES IT SHOW ANY OF THE FOLLOWING BEHAVIORS? CHEWING URINATE/DEFECATE IN HOME BARK/CRY/WHINE NONE 14. WOULD YOU CONSIDER THIS DOG TO BE HOUSEBROKEN? YES NO 15. DOES THE DOG GO OUTSIDE OR USE A PEE PAD/PAPER? OUTSIDE PAPER/PEE PAD 16. WHERE DOES THE DOG SPEND MOST OF IT S TIME DURING THE DAY? KENNELD IN HOUSE CONFINED TO A ROOM IN HOUSE RUNS FREE IN HOUSE OUTSIDE TIED IN YARD OUTSIDE CONFINED BY FENCE LOOSE IN NEIGHBORHOOD 17. WHERE DOES THE DOG NORMALLY SLEEP OVERNIGHT? OUTSIDE KENNELD INSIDE DOG BED OWNERS BED 18. WOULD YOU CONSIDER THE DOG AN ESCAPE ARTIST? YES NO 19. HAS THE DOG ESCAPED YOUR PROPERTY MORE THAN TWICE IN THE PAST 6 WEEKS? IF SO, PLEASE DESCRIBE HOW FOR EXAMPLE DID IT CLIMB THE FENCE, DIG A HOLE, ETC.: 4
20. TO YOUR KNOWLEDGE, HAS THE DOG EVER ATTACKED ANOTHER ANIMAL (DOG, CAT, LIVESTOCK) RESULTING IN SEVERE INJURY OR DEATH? YES NO IF YES, PLEASE EXPLAIN IN DETAIL: 21. TO YOUR KNOWLEDGE, HAS THE DOG EVER ATTACKED OR BITTEN A PERSON? YES NO IF YES, PLEASE EXPLAIN IN DETAIL: MEDICAL HISTORY 1. DOES THE DOG HAVE A REGULAR VETERINARIAN? PLEASE LIST NAME OF VET CLINIC HERE: 2. DOES THE DOG HAVE ANY PAST OR PRESENT MEDICAL CONDITIONS? YES NO PLEASE DESCRIBE: 3. IS THE DOG CURRENTLY ON ANY MEDICATION OR SPECIAL DIET? YES NO PLEASE DESCRIBE: DIETARY HABITS (IT IS NOT UNCOMMON FOR DOGS TO STOP EATING WHEN STRESSED. KNOWING WHAT FOOD AND TREATS THEY ENJOY IS VERY HELPFUL TO STAFF AND ADOPTERS) 1. WHAT BRAND OF FOOD IS THIS DOG CURRENLTY EATING? 5
2. WHAT OTHER BRANDS HAS THIS DOG EATEN IN THE PAST? 3. DOES THE DOG EAT: DRY FOOD ONLY CANNED FOOD ONLY COMBINATION 4. HOW OFTEN DOES THE DOG EAT? FREE FED ONCE A DAY TWICE A DAY 5. WHAT TREATS DOES THE DOG ENJOY? PLEASE FEEL FREE TO TELL US ANY ADDITONAL INFORMATION YOU THINK WILL BE HELPFUL WHEN PLACING THIS DOG INTO A NEW HOME. 6