Owner Surrender Form

Personal Information

Please Note: If you do not fill all required fields, we will not be able to help you.

Information on the Dog

Please tell us why you want to Surrender this dog. Please be specific.


Name of the dog:  Sex of the dog: Male    Female

Age of the dog:  Birth Date if known:

Age is unknown, but approximately:

Is the dog Spayed or Neutered? Yes No
 
What size is the dog? Standard   Miniature   Toy

Weight of dog:

Other Comments:


Please provide the following information to the best of your ability:

Dog General History

Where did you originally get, purchase, or find the dog? Please be specific.


If you purchased the dog from a breeder, did you sign a contract giving the breeder
right-of-first refusal? Yes    No

Breeders Name
Breeders Phone Number

Have you contacted the breeder? Yes    No

If no, why not? Please be specific.


Is this dog registered? Yes    No

Do you have the papers? Yes    No

If so, what is the registry number:   

Do you have a pedigree on this dog? Yes    No

Is the dog:    an Inside Dog    an Outside Dog    Not Sure

Other Comments:

Medical History

If you are the present owner of this dog, please provide information about the dog's veterinarian:

Veterinarian's Name
Veterinarian's Phone Number

If the dog has not been spayed or neutered are you willing pay to have it done? Yes    No

Please share date of last heat cycle of unspayed female:

Has the dog had a heartworm test? Yes    No

If Yes, test was: Positive    Negative

What is the date of the last HW TEST?

If the dog has not been tested for heartworm are you willing to have this done? Yes    No

If the dog is heartworm positive are willing to pay for the heartworm treatment? Yes    No

Is the dog currently on heartworm preventative medication? Yes    No

If not, when was the last date that heartworm preventative was given?  

If yes, what brand of heartworm medication has the dog been on?  

Is this dog current with its vaccinations? Yes    No

What is the date of the last vaccination shots?

If not, are you willing to have the dog given all his vaccinations? Yes    No

Please provide other details of known or suspected medical conditions of this dog.


Other Comments:

By supplying this information,
you are giving your consent for us to contact your veterinarian
regarding this dog's medical history.

Behavior

Is the dog house broken?   Yes    No    Not Quite

This dog: 
Needs to be confined to his/her crate (Explain in Box Below) 

Confined to a certain area of the house (Explain in Box Below)

Has run of the house

Explain:


Will the dog allow you to examine it's body without much trouble?  Yes    No

How does the dog behave around adults?

Friendly    Shy    Nervous

Difficulty with Men    Difficulty with Women

Other (specify):


Is the dog good around children? Yes    No

Is that experience: Good  or   Questionable

Has the dog ever bitten or snapped at anyone. Yes    No

If Yes, please explain & Please be specific.


Has the dog ever shown any aggression towards anyone or other animals? Yes    No

If yes, please explain further:


How does the dog behave at the vet?

Friendly    Shy    Nervous    Aggressive    Has to be Muzzled

Please explain further:


Is the dog good and well socialized around:
Other Male Dogs Yes    No    Not Sure

Other Female Dogs Yes    No    Not Sure

Small Dogs Yes    No    Not Sure

Cats Yes    No    Not Sure

Other Small Animals Yes    No    Not Sure

Please explain further:


Do you feel the dog is overly possessive about his food, treats, or toys? Yes No

Please tell us about other behavior issues this dog may have that you are aware of:


Other Comments:

Training

Please list any commands the dog has knowledge of.


When on a leash, do you walk the dog?    or does the dog walk you?

Has the dog had formal obedience training?

Please explain:


Are you able to foster this dog until a foster and/or adoptive home can be found? Yes No

How did you hear about C.U.R.S.?


We reserve the right to refuse acceptance of any dog.
Acceptance is based on many criteria, one of which is space availability.
We will find the closest, correct foster home or new forever home which is first, closest to your area, if possible. If none is found, we might transport to a open foster home that feels comfortable taking in this dog based on the facts given in the Owner Surrender Form.

I understand that the information contained in this form might be passed on to another rescue org.
Yes No

Additional Comments:

I certify that the information provided on this form is true and correct.  I understand that an physical evaluation of the dog, and a temperment test will be performed by an experienced rescuer and/or volunteer to ensure we feel the dog is rehomeable before we accept this dog into any of C.U.R.S. members foster homes or a forever home. If during the evaluation process we find that information contained in this surrender form to be false, we have the right to turn down acceptance of the dog you are surrendering.

I also understand that the following criteria must be met before C.U.R.S. and any of its members will consider taking my dog as an owner surrender. I also understand that if I am not able to meet these prerequisites, my circumstances I have explained above will be taken into consideration by C.U.R.S. in determining the acceptance of my dog as an owner surrender. I also understand that once I have given up the dog in question, I am in no way to have him/her back unless certain agreements have been made with the rescuer and/or President and Vice President of C.U.R.S.

* Current on vaccines
* Spayed or Neutered
* Have a heartworm check OR
* The owner must make a monetary donation to Catahoula United Rescue Society upon relinquishment of the dog that we are taking in.*

Thank You!