Owner Surrenders and Intake

Intake Form

Please fill out application as complete as possible. All incomplete Applications will not be evaluated.

* denotes a required field

First Name *
Last Name *
Email Address *
Phone Number *
Alternate Phone (Cell): *
Street Address *
City *
State
Major Cross Streets *
What is the Dog's Name? *
Please tell us the dog's date of birth, if unknown, please list approximate age: *
Please list the primary breed of the dog. *
If this dog is a mix, please list the secondary breed here.
What is the sex of the dog? *	Female Male
Is this dog spayed or neutered? *	Yes No
If not, please tell us why?
Is this dog current on all shots (Distemper/Parvo, Rabies & Bordatella)? *	Yes No
If not, please tell us why?
Please tell us why you are turning this dog in (please be specific): *
Please tell us where this dog primarily is kept.	Inside Only-free run of the house Inside/outside with dog door Outside only Crate Outside Kennel/Run Outside Cable/Chain/Tie out Laundry Room or other small room Garage, Barn or Workshop- no access to living areas
Is this dog housebroken? *	Yes No Unknown
Can/does the dog jump or climb fences? *	Yes No Unknown
Can this dog be trusted by itself inside for extended periods of time? *	Yes No Unknown
Can this dog be trusted by itself within a fenced yard? *	Yes No Unknown
Is this dog crate/kennel trained? *	Yes No Unknown
What kind (brand) of dog food do you feed this dog? *
This dog is good with (please check all applicable): *	female dogs male dogs cats small animals horses cattle sheep goats chickens Men Women Children under 5 yrs old Children 5-10 yrs old Children 10 & up Birds Pigs
This dog is NOT good with (please check all applicable):	female dogs male dogs cats small animals horses cattle sheep goats chickens Men Women Children under 5 yrs old Children 5-10 yrs old Children 10 & up Birds Pigs
Please check all the words/phrases that best describe your dog: *	Bites Nips Heels/Hands/Legs/Clothes Mouths Hand (softly) Digs Barks Jumps up Destructive Growling Protective of Food Protective of Toys Protective of People Protective of Children Territorial Happy Affectionate Obedient Intelligent Submissive Fearful of adults Fearful of dogs Fearful of cats Fearful of children Hyperactive Passive Aloof Sociable Quiet Easy Going Gentle Playful Active Intense Focused Demanding Insecure Stubborn Independent Sits for Treats Bored Out-of-Control Food Motivated Toy Motivated Ball Crazy Frisbee focused Fly Ball dog
Has this dog ever bitten a person? *	Yes No Unknown
If you answered yes, please describe the circumstances (be specific):
Was a police report made?	Yes No Unknown
Has this dog ever attacked another animal? *	Yes No Unknown
If you answered yes, please describe the circumstances:
Where did you get the dog from? *	Friend Neighbor Pet Store Breeder Pound Humane Society Rescue Group Found as Stray
Has the dog been obedience trained by a professional obedience trainer? *	Yes No Unknown
If you answered yes to the above question, who was the tainer (please list name and city/state)?
Has the dog been treated for any major illnesses? *	Yes No Unknown
If you answered yes, please describe each illness and he outcome (be specific):
Does the dog have a current Veterinary? *	Yes No Unknown
Please give us the Veterinarian's name and address. *
Do you agree to provide us with all the information we need to place your dog? *	Yes No
Do you agree to foster the dog until we can find it a new home? *	Yes No
Do you agree to our intake policies and procedures? *	Yes No
Do you agree that you have answered all the above questions truthfully and to the best of your knowledge?? *	Yes No
Please give us any other information that may help in placement of this dog or post comments here:
Please submit a photo of the dog you are turning in. (Please upload jpegs only)


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