Contact Information
Name:
Address:
City:
State:
Home #:
Cell #:
Email:
Dog's Information
Dog's Name:
Registered Name:
AKC#:
Sex:
Male
Female
Age:
Color:
If white, is the dog hearing and/or vision impaired?
N/A
Yes
No
Weight:
Are the ears cropped or natural?
Natural
Cropped
Is the dog pure bred?
Yes
No
If no, please list what the dog is mixed with:
Is the dog spayed/neutered?
Yes
No
If no, are you willing to spay/neuter the dog prior to surrender?
N/A
Yes
No
Is the dog microchipped or tattooed?
Yes
No
If yes, list the microchip brand and number and/or the location of the tattoo:
Breeder Information
Breeder's Name/Kennel Name:
Breeder's City:
Breeder's #:
Breeder's Email:
Website:
Do you have a contract with the breeder?
N/A
Yes
No
Have you tried contacting the breeder to return the dog?
N/A
Yes
No
If yes, what was the reason for not taking the dog back?
Dog's Living Conditions/Schedule/General Information
Where is the dog kept when you are NOT home?
Where is the dog kept when you ARE home?
Approximately how many hours is the dog left alone on a typical day?
Is the dog crate trained?
Yes
No
Is the dog potty trained?
Yes
No
Where is the dog accustomed to sleeping at night?
Is the dog allowed on the furniture?
Yes
No
Has this been the dog's only home?
Yes
No
If no, please describe the dog's previous home(s)/living conditions and how the dog ended up at your home:
Please list the dog's usual schedule (sleep, potty, play, etc.):
What type of food is the dog currently fed?
How many times a day is the dog fed?
What amount is the dog fed at each feeding?
Please list any supplements the dog is taking, the dosages, and the frequency:
Veterinarian/Medical Information
Clinic/Veterinarian's Name:
Clinic City:
Clinic #:
Clinic or Veterinarian's Website or Email:
Please select the vaccinations your dog is current on and the next date they are due:
DHPP or DHLPP
Vaccinated for DHPP or DHLPP On:
Next DHPP or DHLPP Vaccination Due:
Rabies
Vaccinated for Rabies On:
Next Rabies Vaccination Due:
Bordatella
Vaccinated for Bordatella On:
Next Bordatella Vaccination Due:
Has the dog been tested for heartworm recently?
Yes
No
Date of last heartworm test:
Results of heartworm test:
N/A
Positive
Negative
If positive, has the dog been treated?
N/A
Yes
No
Has the dog been tested for parasites recently?
Yes
No
Date of last fecal (parasites) test:
Results of last fecal test:
N/A
Positive
Negative
If positive, please list the parasites found and the type of treatment that was administered and when:
Does the dog have any known allergies or medical conditions?
Has the dog ever bloated and/or torsioned?
Yes
No
If yes, describe the procedure(s) performed and when they were performed:
Has the dog had any surgeries besides spay/neuter?
Yes
No
If yes, please describe:
Personality/Temperament
Has the dog been through obedience training?
Yes
No
List any commands or hand signals the dog knows:
List an unusual or difficult behaviors the dog exhibits (car rides, nail trims, vacuum, etc.):
Is the dog good with... Children/Babies
(Please select all that apply) Women
Men
Strangers
Other Dogs
Small Dogs Only
Large Dogs Only
Male Dogs Only
Female Dogs Only
Cats
Other
Please list any known habits the dog has (digging, eating trash, jumping fences, etc.):
Describe the dog's activity level:
Is the dog... Shy
(Please select all that apply) Fearful
Anxious
Nervous
Dominant
Demanding
Excitable
Aggressive
Indifferent
Feral
Please describe any of the selected behaviors in more depth with examples:
Is the dog protective of food, toys, people, furniture, etc.?
Yes
No
If yes, please describe:
Has the dog ever bitten another animal or person?
Yes
No
If yes, please provide an account of the incident(s):
Please describe why the dog is being surrendered?
How soon does the dog need to be surrendered?
Please list any items to be surrendered with the dog (crate, food bowls, meds, blanket, etc.):
The dog MUST be surrendered with a collar and a leash.
How far are you willing to drive to meet a volunteer?
To the best of your knowledge is the information you provided accurate and truthful?
Yes
No
Is there any other helpful information about the dog that we should know?
Would you like to make a contribution to the rescue towards the dog's care while it is in a foster home?
Yes
No
How did you hear about FFGDR?
Releases
Medical Release By checking the medical release box and signing below, I certify that the information I am about to provide is true and correct. Additionally, I agree to call my veterinary clinic and give permission for the release of my pet's medical records to a representative of Forever Friends Great Dane Rescue, Inc.
Release of Pet Ownership By checking the release of pet ownership box and signing below, I hereby agree to transfer full ownership, right, and responsibility of the dog to Forever Friends Great Dane Rescue, Inc. I understand that after this date, I shall have no interest or right to the dog and all decisions regarding the dog shall be made at Forever Friends Great Dane Rescue, Inc.'s sole discretion. I further understand that I am not eligible to adopt the surrendered dog back from Forever Friends Great Dane Rescue, Inc.
Liability Release and Waiver By checking the liability release and waiver box and signing below, I accept this waiver and release Forever Friends Great Dane Rescue, Inc. from any and all liability. I am certifying that all the answers I have given are the truth. I also understand that this information might be shared with another rescue group if they call Forever Friends Great Dane Rescue, Inc. to inquire about the listed applicant(s).
Signature: *
Date of Signature:
Security Code: *
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