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

Shelter's name:

Street Address: City: State: Zip:

Phone Number: 2nd Number: Email:

Contact Person:

Website:

Dog’s name:

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

How long have you had dog at the shelter?

Was dog owner turn in or stray? Select turn in stray

If owner turn in, what was the reason given:

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:

Dog’s general health:

Current on vaccinations? Select yes no

Has dog been tested for Heartworm? Select yes no

If tested, is the dog HW test positive or negative? Select positive negative

How does dog react to the following:

Other dogs:

Strangers:

Men:

Women:

Children:

Crates:

Cats:

Petting:

Giving a treat:

Taking away food:

Giving a toy:

Taking away toys:

Stepping into dog’s space:

Direct eye contact:

Touching feet:

Touching tail:

Pinch test:

Behaviors of your dog:

How does dog walk on leash?

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

How would you describe your dog’s behavior in run?

What commands does your dog know?

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

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

Before your dog can enter into rescue we will need a signed surrender form. When we have a foster home for your dog, this form will be signed at the time they enter into our rescue program. Once we have a foster home for the dog we will need the following paperwork before we can move the 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.