Canine Surrender Form
Owner Information
Owner's Name
Home Phone:
Street Address:
City:
State:
Zip Code:
Cell Phone:
Daytime Phone:
Email Address:
Dog's Information
Name:
Breed:
Purbred or Mixed Breed?
Is the dog altered or intact?
Age:
Eye Color:
Coat Color/Length:
Personality, Quirks and Tricks - Please describe your cat with as much detail as possible.  Likes, dislikes, games, tricks and commands are great informaion.
How many hours a week is the dog used to spending alone?
Other
(please check all that apply)
Don't have enough room for the dog
Moving and can't take the dog with us
Too rough with our kids
Doesn't get  along with other animals
Dog is too hyper
Fond as a stray, but can't keep the dog
Don't have time for the dog
 
How long has the dog lived with you?
Detailed reasons for rehoming the dog:
Veterinary and Medical Information
Name of current vet:
No, past due on all vaccinations
Some:
Please enter the date of your dog's last rabies vaccinations:
Is your dog on flea and tick preventative? If so, which brand?
Vet's Office Address:
 
Yes, current on all vaccinations
Yes
No
Medical history - Please list any past injuries, surgeries, know medical conditions or allergies:
Is the dog microchipped?  If so, please list the microchip company:
 
Agreement to Provide Information
I agree to have my dog's vet reconrds faxed to 866-881-1080 for use by Lost Mittens Animal Rescue
I understand that my dog must be spayed or neutered and up to date on vaccination in order to participate in Lost Mittens Animal Rescue Owner Surrender program
I understand that I must provide photos of my dog.
Postal Mail - a LMAR volunteer will contact you to give you an address
Yes
No
Email - please list cat's name and the word photos in the subject line
I will provide photos of my dog via:
Temperment Information
By signing this document I am ensuring that the above information I provide is true and correct and that Lost Mittens Animal Rescue or it's agent will not be held liable or chargeable for any false informaiton, or any misrepresentations, that I have submitted on this form
I further agree and understand that Lost Mittens Animal Rescue will evaluate this dog to determine whether or not the dog being surrrendered will be considered "adoptable".  Placement is NOT guaranteed.
Signature:
Date:
Driver's License #:
Thank You!  You will be notified by Email
Dog's Gender:
Where did you get the dog?
Is the dog up to date on vaccinations?
You must be 18 years or older to sign this form
Reasons for rehoming the dog
Where does this dog live?
Vet's Phone:
Does your dog have a current Rabies vaccination?
Has the dog ever bitten a person? We do not automatically rule out working with dogs with bite histories. Please provide as much information as possible
If your dog has ever bitten a person, please providea detailed account of each incident, including if any authorities were contacted(Animal Control, etc.)
If the dog is determined to be un-adoptable by Lost Mittens Animal Rescue for any reason prior to placement, I agree to retrieve this animal within two (2) days following notification by Lost Mittens Animal Rescue.
Once we have all required information for the dog, it will be listed on Lost Mittens Animal Rescue website and on other pet sites such as Petfinder and 1-800-Save-A-Pet.
Please enter the date of your cat's last DHLPP vaccination:
No
Yes, did not break the skin
Yes - broke the skin, no medical treatment needed
Yes - broke the skin, required medical treatment but not stiches
Yes - broke the skin, required stitches
Other
Has the dog ever nipped people or snapped at people?
No
Yes
Growls if people go near him when he's eating
Does the dog exhibit any of the following behaviors:
Other
None of the above
Growls if stranger approach his owner(s)
Growls if people go near him when he has a treat
Growls if people go near him when he has a toy
Is the dog good with children?
Yes- good with kids
Good with older kids
No
Other
Is the dog good with cats?
Yes, has been off leash with cats
Yes, has lived with cats
Unknown, has never been around cats
No,  tries to chase/catch cats
Is the dog good with other dogs?
Males dogs
Puppies
Older dogs
Yes, all dogs
Female dogs
Other
No, not good with dogs
If your dog is not good with other dogs, please provide an explanation, and a description of how your dog acts with other dogs
Is the dog well behaved while being brushed, bathed, and having nail clipped?
How soon does the dog need to be rehomed? Please remember that we can only do our best to help as many dogs as possible
Please note below any other information that will help the dog adjust to their new surroundings easier:
Make any comments you'd like below:
When the dog is rehomeds, will you provide permission in writing for the microchip company to change the information to that of the new owner?