Canine Relinquishment Form

Dog Information

Dog's Name*

First

Today's Date*

Dog's age*

Actual
Estimate

Gender*

Male
Female

Spayed/Neutered?*

Yes
No
Pregnant

If female, has she had a heat cycle?

Yes
No

If so, when was her last cycle?

If female, has she had puppies?

Yes
No

If so, how many litters?

Breed*

Mixed Breed
Purebred

Coloring*

Markings*

How long have you had your dog?*

Where or from whom did you obtain the dog?*

What are the specific reasons you need to surrender your dog?*

Behavior

Is this dog completely house-trained?*

Yes
No

Is this dog crate-trained?*

Yes
No

If crate-trained what type of crate did you use?

Wire
Plastic

Have you tried crate training?*

Yes
No

How many hours is the dog left alone on average?*

Does this dog become anxious when left alone?*

Yes
No

Has the dog ever tried to escape the house or yard?*

Yes
No

If yes, how?

How tall is your fence?*

What material is your fence made of? Chain, wood, etc.*

Where is your pet primarily kept?*

Indoor Only
Outdoor Only
Indoor/Outdoor with dog door
Indoor/Outdoor

This dog is fearful/wary of:*

Strangers
Men
Women
Children
Other
Not Fearful

Has the dog lived with or interacted with children regularly?*

Yes
No

If yes, what ages? How is the dog around children?

Has this dog ever harmed a person?*

Yes
No

If yes, who was it & what was the situation? (If no please put N/A)*

You are obligated by law to inform us if this pet has bitten anyone in the past 10 days. Has this dog bitten anyone in the past 10 days?*

Yes
No

Did the bite break the skin?*

Yes
No

If yes, what date did the bite occur, please describe the situation in detail:*

This dog has lived with:*

Female dogs
Male dogs
Cats
Livestock
Other
None of the above

This dog does well with:*

All dogs
Male dogs
Female dogs
Cats
Livestock
Other
None of the above

This dog does NOT do well with:*

All dogs
Male dogs
Female dogs
Cats
Livestock
Other
None of the above

Commands your dog knows (check all that apply)*

Dog's favorite activities*

If other, please describe:

Dog's favorite toys:*

How does this dog walk on leash? (check all that apply)*

Good
Doesn't Pull
Not Good
Pulls
Needs Harness
Other

If other, please describe:

How Would you describe your dog's activity level?*

Calm
Moderate
Energetic

Describe your household.*

Quiet/Calm
Active
Noisy
Other

If other, please describe:

Does your dog guard any of the following from people?*

Food
Toys
People
Other

If other, please describe:

Does your dog guard any of the following from other dogs?*

Food
Toys
People
Other

If other, please describe:

Have you attempted to correct behavior by training, management, and/or medical treatment?*

Yes
No
N/A

Were you able to correct the problem?*

Yes
No
N/A

Please Explain

Use the space below to tell us more about this animal - please be honest to help us find the best possible placement:*

Pet's Medical Information

When was the last time your dog was seen by a Veterinarian?*

Current Veterinarian or Clinic:*

Does your dog require special handling at the vet? Describe:*

Does your dog have known health issues (allergies, seizures, etc) or any old injuries? Describe:*

If applicable, what have you been doing to control the issue(s)?*

Special Diet
Medication
Nothing
Other
N/A

If you marked other, please describe.

Is your dog on any type(s) of medication currently?*

Yes
No

Medication Names:

How much? How Often?

What food does your dog eat?*

What happens if your dog's diet changes?*

Surrendering Party Information

Owner or Agent's Name (as it appears on driver license)*

First Last

Driver License Number*

Email*

Mailing Address*

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

Home phone*

Alternate Phone

Upload Photo of your Drivers License or ID

Max. file size: 64 MB.

Consent*

By signing your name below, you give up all rights to the animal and surrender him/her to Ark-Valley Humane Society. Ark-Valley Humane Society is a minimal euthanasia facility, however we do euthanize animals when they do not fit our criteria for adoption. Our policies on euthanasia are aimed at protecting our staff, volunteers, potential owners, animals at the shelter, this animal, and the community at large. If you have specific questions about our policy, please ask an Ark-Valley Humane Society employee. Ark-Valley Humane Society is not obligated to disclose if an animal is euthanized, adopted, or transferred.

I certify that I own this animal or am acting as agent for the owner. If I am acting as agent for the owner, I certify that I have permission to surrender this animal and to relinquish all ownership rights of the animal on behalf of the owner. I certify that the said animal has not bitten anyone in the past 10 days. If the animal has bitten someone in the last 10 days, I am obligated to notify Ark-Valley Humane Society of the date and occurrence. I hereby relinquish all rights of ownership for this animal to the Ark-Valley Humane Society, Inc. and agree that the disposition of this animal be at the discretion of Ark-Valley Humane Society. I request that copies or summaries of the medical records for my pet be released to Ark-Valley Humane Society.

I agree to the following statement

Signature*

Date

CAPTCHA

719-395-2737

Owner Relinquishment Form - Canine

Dog Information

Behavior

Pet's Medical Information

Surrendering Party Information

719-395-2737

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