EmailMe Form - Homeward Bound Dog Owner Surrender Questionnaire

Basic Information

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Information about your dog

Name of Dog *

Are you the dog's legal owner? *

Breed of Dog *

Age of Dog *

Approximate current weight *

Is the dog spayed or neutered? *

If your female is not spayed - do you remember when her last heat cycle was ( can be approx) *

Is the dog current on its vaccinations? *

Is the dog microchipped? *

Reason for surrendering this dog: *

How long have you had this dog? *

Where did you get this dog? *

The dog is: *

Housebroken

Paper trained

Sometimes has accidents

Not housebroken

Is the dog crate trained? *

How many times a day is the dog exercised? *

Where is the dog kept when no one is home? *

Where does the dog sleep at night? *

How many hours is the dog left alone during a work day? *

How does the dog act when left alone? *

Dog's favourite activites? *

Training: *

Obedience classes

Home training

Private professional training

No formal training

Commands known: *

This dog has lived in the same household with: *

How does the dog get along with the others noted above? *

Check as many of the following that describe the dog's behaviour and habits: *

Does the dog like the company of small children? *

Does the dog like the company of cats? *

Does the dog like the company of other dogs? *

Is the dog overly protective of its food/toys/treats? *

Is the dog overly protective of family? *

Is the dog overly protective of its property? *

How does the dog react to strangers? *

Has this dog ever snapped at a human or other animal? If yes, please describe when and why. *

Has this dog ever bitten a human or other animal? If yes, please describe when and why. *

What is the dog fed, how often and how much? *

Please list any medication currently taken or special needs the dog may have: *

Is there anything else we should know about this dog?

How soon does the dog need to be placed? *

Current picture of dog *

Are you reaching out to other rescues *

YES

NO

IF WE ARE NOT ABLE TO HELP, DO YOU GIVE CONSENT FOR US TO SHARE YOUR SURRENDER FORM AND CONTACT DETAILS WITH RESCUES WHO MAY BE ABLE TO HELP? *

YES

NO

AGREEMENT

I attest that the information provided on this application is true and accurate to the best of my knowledge. By submitting this application to the Homeward Bound Rescue, I agree and consent to the collection, use and transfer of my personal information for the purposes of processing my application.

Name (Signature) *