Upon submitting this form, you will be taken to a confirmation page where you will then be able to email the previously mentioned photos.

Owner’s name:

Street Address: City: State: Zip:

Home Number: 2nd Number: Email:

Dog’s name:

Has the dog ever bitten? Select yes no If yes, please explain:

How long have you had dog?

Where was dog purchased?

If from breeder, breeder’s name and contact info:

Description of your dog:

Sex: Select Male Female

Age: month/years

Height at shoulder: inches

Weight pounds

Color

Mix or purebred? Select mix purebred

Spayed or neutered? Select yes no

Papers? Select yes no

Is dog housebroken? Select yes no

Vet Information:

Name of your vet:

Vet’s contact info:

Current on vaccinations? Select yes no

Has dog been kept on Heartworm treatment? Select yes no

Has dog been tested for Heartworm? Select yes no

How does dog react to the following:

Other dogs:

Strangers:

Men:

Women:

Children:

Crates:

Car rides:

Petting:

Taking away treats:

Taking away toys:

Taking away food:

Touching feet:

Touching tail:

Behaviors of your pet:

Does dog pull when on leash? Select yes no

Is dog afraid of storms? Select yes no

Does dog show aggression if approached when eating? Select yes no

Does dog come when called? Select Sometimes yes no

Is dog destructive in home? Select yes no

Which of the following terms would you use to describe the dog: (check all that apply)

Where is dog kept most of the time? (house, yard, crate, confined room)

Please list any behaviors that your dog needs improvement ex. barking, jumping on people, runs away, fearful of mower/vacuum, etc.):

Why are you surrendering dog?

Once we have a foster home for your dog we will need the following paperwork before we can move your dog: 1.) copies of all vet work 2.) signed MWBCR surrender form 3.) if the dog is registered, a copy of the papers. Paperwork must be received before the dog goes into our foster program.

In addition to the paperwork, we will ask for a $50 donation. Your donation will be used to help care for our dog while it is in our foster care program. We will also ask for your assistance to get the dog started on its transport to its foster home.

And finally, it will be helpful if you can send along some food so we can transition the dog slowly over the first week to new food. If you have a bed, crate or toys that would make your dog more comfortable during its re-homing, we will be happy to accept them as well.