AWPGA Rescue Surrender Intake Form

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Any questions prior to submission may be directed to the
AWPGA Rescue Chairperson, Martha Ingram
Email: martha.ingram1@gmail.com

Email *

YOUR CONTACT INFORMATION

Full Name *

Email *

Full address (house #, street, city, state, and zip code) *

Cell Phone number *

Secondary Phone number

DOG INFORMATION

Registered Name, if applicable *

Call Name *

Registry (i.e. AKC, NAVHDA, Other)

Please provide Registry Number

Sex *

Male

Female

Date of Birth, if known *

YYYY

Microchip/Tattoo #:

Height at shoulders

Current Weight

Dog Breeder, if known *

Spayed or Neutered? *

Yes

Travels Well In Car? *

yes

Housebroken? *

Yes

Crate Trained? *

Yes

Current On Vaccinations? *

Yes

Temperament *

Calm

Medium Energy

High Energy

When Outside, Dog is... *

Contained by Fence (Please describe below, including Fence Height)

Invisible Fence

Leash Walked

Runs Loose

Other (Please describe below)

Describe Fence Height, Other *

Good With *

Children

Dogs

Cats

Other Pets

Other, Please Describe Below

Required

Please Describe, details are helpful:

Any History of Aggression? *

Yes

Please describe, details are helpful

Exercise Needed (minutes/day): *

Please Describe, details are helpful:

Health Problems? *

Yes

Please Describe, details are helpful:

Hunting Experience? *

Yes

Please Describe, details are helpful:

Behavioral Problems? *

Yes

Please Describe, details are helpful: *

Commands Known & Response: *

Other Information About the Dog (likes/dislikes, past history): *

Reason for Placing Dog Up for Adoption: Shelter said owners gave her up because they did not have enough time for her now *

Any Additional/Helpful Information When Placing this Griffon with a new family: *

*Please email photos of your dog to awpgarescue@gmail.com

Include (1) the dog's name; (2) frontal, (3) Side view, (4) Action shots

Surrender Agreement

I/we am/are the true, rightful and legal owners of the dog identified above or have full legal authority to act on behalf of the owners of such dog. The surrender contemplated hereby does not infringe or violate the rights of any other person. By signing below, I/we am/are hereby surrendering such dog, and conveying full and complete right, title and interest in and to the dog, to AWPGA Rescue. AWPGA Rescue will assume legal ownership of the dog until the dog is adopted by a new owner. I/We understand and agree that by surrendering and relinquishing ownership of the dog, I/we will not be able to determine its final placement. I/we further understand and agree that if I/we seek to reclaim the dog, I/we will have to go through the AWPGA Rescue‘s regular adoption procedures, including payment of adoption fees. I/we also understand and agree that if I/we breach any term of this agreement, including by misrepresenting our ownership of the dog or by failing to deliver custody of the dog to AWPGA Rescue, its representatives or authorized agents, then I/we shall be liable for, and shall promptly pay to the AWPGA Rescue, liquidated damages in the amount of $130. I/we agree that such amount is fair and reasonable. I/we understand that I/we remain responsible for the costs of care and upkeep of the dog while it remains in my/our custody.

Legal Substitute For Signature *

I AGREE THAT BY SUBMITTING THIS FORM BY E-MAIL SHALL BE TAKEN AS A LEGAL SUBSTITUTE FOR MY SIGNATURE.

A copy of your responses will be emailed to the address you provided.

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