Airedale Rescue and Adoption

                     

Date____/____/____
                                         
Referred by_______________

Surrender Form                                       


Dog’s Name______________ Age___  Sex___  Size___  Weight_____  

Spayed/Neutered? Y / N     How long have you had him/her?______

Bought as a puppy?______  Adopted at what age?_________

Owner____________________________________ Phone____-____-______

E-mail____________
Address   (If moving, please give new address as well) ______________________________________________________________         ______________________________________________________________
NOTE:Please notify the breeder, if available, before surrendering to rescue.  All good, responsible breeders will  want to take back any dog they’ve bred, regardless of age, for the privilege of placing that dog in a suitable new home themselves.

Breeder______________________ Address_____________________________

Phone____-_____-________

Breeder’s response:__________________________________________________

REASON FOR GIVING UP THIS DOG:______________________________________

Health Record: Please ask your vet for a copy of your pet’s complete medical history.

Veterinarian:_________________________________________________________ 

Phone____-____-________

    Dates of last:DHLP-P__/__/___  Rabies__/__/___  Bordetella__/__/___ 

    Heartworm Check__/__/___    Currently on Heartworm Preventative?____  

Brand____________________      Date last pill_______

Any Allergies?__________________   

Other Chronic Problems?_______________________________________________

Currently on any medication? If so, what and what for?_______________________

Diet: Brand of food___________________   How much and when fed___________

HOW YOUR DOG LIVED WITH YOU   (Please check where applicable:)
    Inside Dog:     House___        Apartment___      Walked____      Tied out____     

    Fenced Yard___    Outside dog:    Chained___     Fenced-Yard___     Dog Run___

Ages of all current family members:________________________________________

Has been exposed to and is good with :

     Men___     Women___    Young Children___    Other Dogs___    Cats___

Has been: Housebroken ___     Crate trained ___      Leash trained ___     

Obedience trained _____     Had run of the house____    Allowed on  furniture ____  

Had a dog bed_____     

In what room did he/she sleep?__________    

Where was he when no one was home?___________            

Was he/she  destructive?  Yes___No___   If so, only when left alone?_____

Any time?__________  

Any fears?_____________________  Favorite toy/activity______________________

Is there anything the new owner should NOT try to do with the dog?____________                                    (Over)                    

Is there anything you DO NOT LIKE about this dog?___________________________

____________________________________________________________________

Does he/she ever snarl or growl?______ 

If so, under what circumstances?__________________________________________

HAS THIS DOG EVER BITTEN ANYONE?  Y / N      

IF SO, WHEN?  (Date)    _____/_______/________
WHAT WERE THE CIRCUMSTANCES?_______________________________________

____________________________________________________________________

Please bring all papers you have on this dog with you when you come to release  him/her to Airedale Rescue. Although we do not give registration papers with our adoption dogs, it is helpful for our records to keep track of their origins. Please bring  his/her health records and all veterinary certificates (such as rabies and proof of neutering) which are required to obtain proper licensing for the dog.

I certify that I am the legal owner of this dog, free and clear of all other interests.
On _________, 200__, I hereby transfer ownership of ________________________to
________________________ of the Airedale Rescue and Adoption.

I understand that every effort will be made to place my dog in the best home possible, suitable to his personality.  I hereby relinquish all claims to said dog, and I understand that if the Airedale Rescue and Adoption Service concludes that this dog is unadoptable because of health or temperament reasons only, he/she will be humanely euthanized by a veterinarian.

I further certify that this dog has not bitten anyone within the last ten (10) days.

By my signature below, I hereby authorize the above-named dog’s veterinarians to release all medical records to _______________________ on request in person or via fax.


Signed:_________________________________     Date  ____/____/______

Witness:_______________________________      Date  ____/____/______

Every dog accepted by the Airedale Rescue and Adoption is properly clipped, bathed, brought up to date on all shots, checked for heartworm, neutered/spayed (if not already done), treated for any ailments including heartworm infestation, and kept in one of three foster homes available.  Sometimes these foster homes are already filled, and one or more of the adoptable dogs have to be kept for a time in a local boarding kennel.

While an adoption fee helps to generally cover routine veterinary expenses, there are times when extra measures are required to medically make a dog acceptable for adoption, and certainly there is no money left from an adoption fee for boarding or advertising. 

For these reasons, we humbly ask that you find it in your heart to help us with the financial burdens of placing your dog by giving a donation.  Please make any checks payable to Airedale Rescue.

If you have any questions, please do not hesitate to call.

Airedale Rescue and Adoption: