RCHS Dog Surrender Form
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Dog Information
Dog's Name *
Can you keep the dog until we find him/her a home? *
How soon do you need a home for your dog?
Dog's Breed *
Dog's Gender *
Dog's Age *
Dog's Weight *
Describe your dog as best as possible *
Why are you giving up your dog? *
Describe the ideal adoptive home for you dog *
If you are surrendering the dog because of behavior problems, would you be willing to work with a trainer to resolve the problem?
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If you've already tried addressing your dog's behavioral problems, please explain how
Health Information
Name of your dog's veterinarian and clinic *
Please include their phone number and all names your dog may be listed under (if not yours).
Date of most recent vet visit *
Vaccination dates *
Include past vaccinations or due dates for Parvo, Distemper and Rabies.
Has your dog been tested for heartworms?
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If you answered 'Yes', please list the most recent heartworm test date and result
Has the dog been kept on regular heartworm, flea and tick prevention? *
If you answered 'Yes, other schedule', please describe when the heartworm, flea and tick prevention were given
Does the dog have any past or current injuries or health problems? *
If you answered 'Yes', please describe the injuries or health problems
Is the dog currently on any medications or prescription diets? *
If you answered 'Yes', please describe the medication or prescription diet
What is your dog's current feeding schedule? *
What food is your dog fed currently? *
Dog's Background
How long has this dog lived with you? *
Where was the dog acquired? *
Where is the dog allowed?
Indoors, Outdoors, only certain rooms of the house...
How much time does the dog spend outdoors on an average day? *
How much time does the dog spend indoors on an average day? *
Where is the pet when left alone at him? *
In a crate, yard, gated off in a room, roaming the house...
How many hours is the dog usually left unsupervised? *
Where did you leave the dog when you went on vacation?
Does the dog regularly escape your yard? *
If you answered 'Yes', when does the dog try to escape from the yard?
Is the dog a fence jumper? *
What type of training has the dog had in the past? *
If you answered 'Other', please describe the type of training the dog received
What behaviors does the dog know on cue?
Is the dog house trained? *
If the dog is not house trained, has he/she been seen by a vet to rule out medical causes?
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If you answered 'Yes', what were the results of the vet visit to address the house training?
Is the dog crate trained? *
Does the dog regularly walk on a leash? *
Has the dog been around children? *
Has the dog been around cats? *
Has the dog been around other dogs? *
Is the dog aggressive towards anyone or anything? *
If you answered 'Yes', please explain how the dog is aggressive
Does the dog lunge or bark at other dogs or people when on leash? *
Has the dog ever bitten, snapped or growled? *
If you answered 'Yes', please detail any bitting, snapping, or growling behavior
Does the dog tend to bark frequently? *
If you answered 'Yes', please describe the typical situtations in which the dog barks
Does the dog have any other bad habits you'd like to mention?
Your Information
Your Name *
Your Phone Number *
Street Address
City, State & ZIP
Email Address *
Help Us Help You
To find your dog a home quickly, please consider emailing us pictures of your dog to dog-coordinators@rchsks.org
Do you have any other questions, concerns or comments for us?
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