Surrending A Dog - Boston Dog Rescue West Roxbury, MA

The more information we have about your dog, the better chance we have of placing him/her in an appropriate foster and eventual adoptive home. Please be very truthful and as detailed as possible to assist us in our efforts.

Thank you.

Once your form has been reviewed, one of our volunteers will be in touch via email or phone to discuss your situation.

	Owner's Name	(person living with dog)
	Co-owner's Name
	Do you both currently reside with this dog?	Yes No If No, please fill out both addresses & phone numbers
	Owner
	Owner's Address
	Owner's City
	Owner's State	Owner's Zip
	Owner's Home Phone
	Owner's Cell Phone
	Owner's Email
	If Co-Owner resides at a different address
	Co-Owner's Address
	Co-Owner's City
	Co-Owner's State	Co-Owner's Zip
	Co-Owner's Home Phone
	Co-Owner's Cell Phone
	Co-Owner's Email

	Dog's Name
	Breed(s)
	Age
	Weight	lbs
	Sex/Altered?	Male Neutered Female Spayed If not altered, will you pay to have this dog altered before surrendering him/her? Yes No
	Housebroken?	Absolutely, 100%, never has an accident in the house. Most of the time, but has an accident about once a week. Not really. Not at all. The dog has no clue. We are use to housebreaking, so please be truthful.
	Is this dog up to date on all his/her shots?	Yes No
	Does this dog have any known health issues?	Yes No
	If Yes, please describe, including medications/treatments, frequency of vet visits:
	Why do you need to give up this dog? (Give as much detail as possible.)
	Does this dog like food such as meat, vegetables or eggs?	Yes No
	If so, what and how often?
	Does this dog enjoy the company of (check all that apply):	Men? Women? Children? Other Dogs? Cats? Other Animals? What Kinds?
	Does this dog have a history of jumping fences?	Yes No If Yes, how high?
	Does this dog have a history of (check all that apply):	Digging Chewing, on what? Frequent Barking (describe circumstances):
	Does he/she jump on people?	Yes No
	Does the dog enjoy meeting new people?	Yes No If the answer is No, how does he/she respond? Aloof Reserved Fearful
	Does he/she	growl and back up, bark and move forward, sit or stand and wait to be approached, tail wagging?
	Please describe a typical meeting:
	Has this dog been to a group training class?	Yes No
	If so, who handled the dog in class?
	Have you had any in-home, private training lessons?	Yes No
	If this dog has had professional training, can we please have the Name and Phone Number of the trainer? Trainer's Name Phone Number
	Is this dog affectionate with his/her family?	Yes No
	How does he/she react when you touch their feet?
	What happens when you touch his/her tail?
	Does he/she cooperate when having their teeth examined?	Yes No Ears examined?Yes No
	Is he/she comfortable when someone is touching or holding their collar?	Yes No
	Will he/she guard (protect, keep you away from) certain items or locations?	Yes No
	If Yes, please describe
	Is the dog is cooperative during grooming?	Yes No
	What are the dog's good points?
	To your knowledge, has this dog ever been abused?	Yes No If Yes, by a Man Woman or Child
	If Yes, please describe abuse
	Is this dog's life in imminent danger because of a current abuse situation?	Yes No
	If Yes, please describe
	How often does the dog come to you for attention?
	What kind of playtime or exercise is this dog currently given? What kind of playtime or exercise does this dog enjoy most?
	How soon are you looking to place your dog?
	Would you be able to foster the dog until a permanent home is found?
	If so, how long would you consider ‘fostering’ your pet?
	Please understand that we have few foster homes and so foster care is not always readily available.

I certify that I am the owner of this dog, free and clear of all other interests. I certify that this dog is not possessed of any dangerous or vicious propensities and has never bitten or attempted to bite any person or animal, and that I have not willfully concealed information about the dog that might indicate such propensities. I certify that I have answered the questionnaire above truthfully and to the best of my knowledge regarding this dog.

The following box is optional. We will not share your information with anyone outside our rescue unless you check the box below.

If Boston Dog Rescue cannot take this dog into it's foster program, I give Boston Dog Rescue my full permssion to share all of the information on this questionnaire with other rescues who might be able to help me in placing my dog.

Owner's Signature	Date
Co-Owner's Signature	Date

Boston Dog Rescue
675 VFW Parkway, #108
Chestnut Hill, MA 02467-3656
adoptions@bostondogrescue.com