Surrender Form Surrender Form and Agreement. Please enable JavaScript in your browser to complete this form. - Step 1 of 7Identification and Contact InformationName *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *EmailConfirm EmailMobile or Primary *Other PhoneNextVeterinarian InformationName *FirstLastPhone Number *Fax NumberHas the dog seen a veterinarian at least once a year? *YesNoIs the dog up to date on all vaccines? *YesNoUnknownDate of last vaccinationsDoes the dog have any diagnosed medical problems? *YesNoPlease list all diagnosed medical problems. *Does the dog currently take prescribed medications? *YesNoPlease list all current medications.Has the dog had any surgeries? *YesNoPlease list the surgeries. *NextInformation About Your DogDog's Name *Why are you surrendering your dog? *Approximate Age of the Dog (Estimate age is OK). Selected Value: 0 Breed *DalmatianDalmatian Mix-BreedColor *Liver & WhiteBlack & WhiteotherPlease describe the color. *Gender *MaleFemaleSpayed or Neutered *YesNoMicrochip *YesNoTattoo *YesNoNextInformation About Your Dog - ContinuedWhere did you get your dog? *BreederRescue OrganizationCounty Animal FacilityOtherPlease describe where you got your dog. *House Trained? *YesNoCrate Trained? *YesNoWhat does your dog eat? *How many times per day and what amount does your dog eat? *What is the dog given for treats? *Does the dog eat people food? *YesNoNextBehavioral CharacteristicsDoes the dog know basic commands? *YesNoDoes the dog walk well on a leash? *YesNoDoes the dog travel well in the car? *YesNoIs the dog afraid of thunder or loud noises? *YesNoIs the dog used to sleeping in your bed? *YesNoIs the dog used to sleeping in a crate? *YesNoIs the dog good with young children? *YesNoUnknownWhat ages are the children? *Is the dog good with other dogs? *YesNoUnknownIs the dog good with cats? *YesNoUnknownNextBehavior Characteristics - ContinuedDoes the dog have separation anxiety? *YesNoHow does the dog react to strangers? *ShyFriendlyAggressiveProtectiveHow does the dog interact with other dogs? *ShyFriendlyAggressiveProtectivePlease check all that apply. *Very ActiveCouch PotatoQuietBarks a lotPlayfulAffectionateDistantFearfulIndependentEscape ArtistFence Jumper - 5 FtFence Jumper - 6 FtHas this dog ever bitten anyone? *YesNoWhen and under what circumstances? *Was animal control involved? *YesNoWhat was the outcome? *NextI understand and agree with the following terms:I am the legal owner of the dog named * I am surrendering the dog to Dalmatian Rescue of South Florida The dog will be made available for adoption or live out the remainder of it's life in rescue. If the dog is microchipped it will be transferred to DRSF and my name will be removed. Medical records will be released to DRSF as part of this agreement. All information given on the previous pages is true to the best of my knowledge. Signature *Clear SignatureCaptcha * = NameSubmit Share this:FacebookXLike this:Like Loading...
