SURRENDER FORM

		SURRENDER FORM
		Please send an email to kydoxierescue@aol.com to verify your application receipt Several times a week we receive emails or calls from owners who feel they must surrender their pets. We feel pets are family members and should remain in their homes until they die from old age. Only extreme circumstances should require a pet to be surrendered to rescue from its family. Families have a responsibilty to make choices that provide for the care of their pets throughout their lives. These are the types of circumstances we feel should not result in the surrender of a family pet: 1. We now have toddler 2. We are moving where dogs are not accepted. 3. Vetting expenses are too high 4. I've lost my job or home 5. I work long hours and dont have time for my dog There are good reasons a family can no longer care for a pet. It may be the owners health or death in the family. Or it may be a back injury the family just cannot afford for the pet. Rescue is set up to support shelter animals that have 5-7 days before euthanasia . Those animals receive first priority. Owner surrender animals are put on a waiting list as space is available and we also require a fee to accept an owner surrender pet. Remember it costs to feed, board and care for your pet even if it is up to date on shots and neutered. If your pet has behavior problems it may require a behaviorist to retrain your dog. Please complete the form below and follow with an email after you have worked through all other sources of placement. Some of the questions below may seem intrusive. They are meant to be informative, so we may find the best home for your pet. This form is for email contact information. Final surrender is not completed until pet is actually surrendered physically. Owner may cancel surrender prior to pickup. We always encourage owners in their efforts to solve problems with pets. We also support any effort an owner makes in self-placement of their pet. However, we as rescue workers, are there to assist an owner in placement whenever necessary. WE ARE NOT HERE TO PROVIDE EUTHANASIA FOR YOUR PET IF YOUR PET IS SERIOUSLY ILL , PLEASE TAKE IT TO YOUR VETERINARIAN...THERE ARE PROGRAMS WHO WILL HELP YOU WITH THE COST OF TREATMENT FOR YOUR DOG......PLEASE HELP US FIND YOUR PET THE BEST POSSIBLE NEW HOME BY TAKING THE TIME TO COMPLETE THE FOLLOWING QUESTIONAIRE..THANK YOU PET IDENTIFICATION-USE TAB KEY TO GO FROM SPACE TO SPACE SECTION 1 Client information: Owners name Owners email address Owners address Owners Phone H w VeterinarianVet Phone NAMEBREED ALSO ANSWERS TO:DATE OF BIRTHIF UNKNOWN, HOW OLD WHEN YOU ACQUIRED IT? APPROXIMATE AGE? ( )MALE ( ) FEMALE COLORAPPROX. WT HOUSETRAINED?( )YES ( )NO DOES IT POTTY ON LEASH OR RUN FREE? HAS THE DOG HAD PREVIOUS OWNERS? DID YOU GET YOUR PET FROM ? BREEDERPET STOREANIMAL SHELTERFRIEND OTHER? HOW DOES YOUR DOG SPEND THE MAJORITY OF ITS TIME? WHERE IS YOUR DOG KEPT OUTDOORS? HOW OFTEN EXERCISED?HOW LONG? MORE THAN 10 MIN 45 MIN1HR2 HR BRIEFLY DESCRIBE HOW DOG IS EXERCISED WHEN IS YOUR DOG FED? AMPMBOTH WHAT DO YOU FEED YOUR DOG? CANNEDDRYTABLE SCRAPSTREATS DESCRIBE THE DOGS FEEDING HABITS? FINICKY GOOD APPETITE VORACIOUS WHAT ARE YOUR DOGS FAVORITE TOYS? WHAT SORT OF PLAY DOES YOUR DOG ENJOY MOST? BALL PLAYCHASE GAMETUG WHERE DOES YOUR DOG SLEEP? BEDROOM KENNELKITCHEN OTHER SECTION 2 HAS YOUR HOUSEHOLD CHANGED SINCE ACQUIRING YOUR DOG? YES NO IF YES, DESCRIBE, DOES YOUR DOG ENJOY CHILDREN? PLEASE DESCRIBE YOUR DOGS INTERACTION WITH OTHER ANIMALS IN THE HOUSEHOLD: DESCRIBE HOW YOUR DOG BEHAVES AROUND OTHER DOGS SECTION 3 WHY DID YOU DECIDE TO ACQUIRE A DOG? COMPANIONFOR CHILDPROTECTION DESCRIBE YOUR DOG'S BEHAVIOR AS A PUPPY. ANYTHING UNUSUAL/ WHY DID YOU CHOOSE THE BREED? HAVE YOU OWNED OTHER DOGS IN THE PAST? YESNO SECTION 4 DESCRIBE YOUR DOG'S REACTION TO BEING LEFT ALONE? DESCRIBE YOUR DOG'S BEHAVIOR WHEN YOU RETURN HOME? DO YOU USE A CRATE? IF YES, WHEN DID YOU BEGIN TO CRATE YOUR DOG? HOW MANY HOURS A DAY IN A CRATE? LESS THAN...5 HRS 10 HRS. 15 HRS SECTION 5; HAS YOUR DOG EVER BEEN TO OBEDIENCE SCHOOL? PRIVATE GROUP HOW MANY WEEKS OF TRAINING? DOES YOUR DOG COME WHEN CALLED?SIT OR LIE DOWN ON COMMAND? DOES YOUR DOG PULL WHEN WALKED? SECTION 6: WHAT IS YOUR DOG'S MOST UNDESIRABLE BEHAVIOR? WHEN DID YOU FIRST NOTICE THE PROBLEM? RANK THE SEVERITY OF THE PROBLEM. MILDMODERATESEVERE HOW OFTEN DOES THE PROBLEM OCCUR? FREQUENTLY OCCASIONALLYRARELY HAS THERE BEEN A RECENT CHANGE IN FREQUENCY OR SEVERITY? YESNO HAVE THERE BEEN ANY CHANGES IN THE HOUSEHOLD THAT COULD HELP TO EXPLAIN THE WHAT HAVE YOU DONE SO FAR TO CORRECT YOUR DOG'S BEHAVIOR PROBLEM? WHY DO YOU THINK THE DOG IS EXHIBITING THE BEHAVIOR PROBLEM? SECTION 7: DOES YOUR DOG EXHIBIT ANY OF THE FOLLOWING BEHAVIOR PROBLEMS? NEVER OCCASIONALLY OFTEN HOUSE SOILING, (URINATION, DEFECATION, MARKING) EXCESSIVE BARKING OR HOWLING DESTRUCTIVE CHEWING, DIGGING JUMPING UP ON GUESTS OR OWNERS MOUTHING ON HANDS OR CLOTHING CHASES (CARS, PEOPLE, OTHER DOGS) OBJECT AND FOOD STEALING DOMINANCE TESTING (PUSHY BEHAVIOR SEXUAL BEHAVIOR TOWARD HUMANS, ROAMING? OVERLY SUBMISSIVE OR FEARFUL DOES YOUR DOG EXHIBIT AGGRESSION OR THREATEN FAMILY MEMBERS? YESNO DESCRIBE EPISODES OF AGGRESSION DOES YOUR DOG OVERREACT TOWARD GROOMING /HANDLING EFFORTS?YES NO IS YOUR DOG AGGRESSIVE TOWARD NON FAMILY MEMBERS? YES NO DESCRIBE THE DOG'S REACTIONS (GROWLS, GLARES, BARES TEETH, BARKS , BITES)UNDER THE FOLLOWING CONDITIONS: NEVER OCCASIONALLY OFTEN WHEN EATING WHEN PLAYING CHEWING A TOY APPROACHED WHEN SLEEPING WHEN PUNISHED WHEN PEOPLE VISIT WHEN VISITORS ENTER YARD WHEN REACHED FOR OR TOUCH WHILE PUTTING IN CRATE ___________________________________________________________________________ SECTION 8 HOW OLD WAS YOUR DOG WHEN IT EXHIBITED THE FIRST SIGNS OF AGGRESSIVENESS? IS THERE ANYONE WHO THE DOG IS NEVER AGGRESSIVE TOWARDS/ DOES YOUR DOG SUFFER FROM ANY PHYSICAL CONDITION THAT MIGHT EXPLAIN ITS AGGRESSIVENESS? IS YOUR DOG MORE AGGRESSIVE TOWARD MALES OR FEMALES? HAS YOUR DOG EVER KILLED ANY ANIMALS? DOES YOUR DOG SHOW SIGNS OF FEAR PRIOR TO BECOMING AGGRESSIVE? DESCRIBE THE SEVERITY OF PAST BITES: DESCRIBE IN DETAIL THE LAST BITE INCIDENT(WHAT, WHEN, WHERE AND WHY?) ANY ADDITIONAL COMMENTS OR INFORMATION THAT YOU THINK I SHOULD KNOW? SECTION 9 IS IT ACCUSTOMED TO USING A DOGGIE DOOR? ( )YES ( ) NO PUPPY PADS? ( )YES ( ) NO SPAYED/NEUTERED? ( )YES ( )NO IF NO, WHY NOT? MICROCHIPPED? ( )NO ( )YES IF YES, MICROCHIP # MICROCHIP CO> AKC REGISTERED? ( )NO ( ) YES REGISTRATION # LAST ANNUAL SHOTS?RABIES SHOT? BORDETELLA?RABIES TAG#_ HEARTWORM TESTED ON?RESULTS? NAME OF H/W PREVENTATIVEDUE ON FLEA & TICK PREVENTATIVEDUE ON_ ON MEDICATION?( ) YES ( )NO IF YES, FOR WHAT? BEEN HOSPITALIZED OR TREATED FOR MAJOR INJURY? ( )NO ( )YES IF YES, EXPLAIN _ HAS YOUR PET EVER BEEN TREATED FORBACK PROBLEMSEPILEPSY FLEASDIABETESASTHMAURINARY INFECTIONS OTHER HEALTH ISSUES:_ WHERE WAS THIS DOG OBTAINED? GENERAL INFORMATION KDR WILL ACCEPT A PET ONLY IF IT IS ADOPTABLE WITH MEDICAL TREATMENT AND /OR BEHAVIOR MODIFICATION IT CAN BECOME ADOPTABLE. PLEASE BE HONEST WHEN ANSWERING THE FOLLOWING QUESTIONS. THIS INFORMATION IS VERY IMPORTANT FOR US TO KNOW WHEN SEEKING A SUITABLE FOSTER HOME AND A PERMANENT HOME FOR YOUR PET BASED ON THE INFORMATION YOU GIVE US. HOW WOULD YOU DESCRIBE YOUR DOGS TEMPERMENT AROUND? OTHER DOGS?--------------------------------( )GOOD ( )FAIR ( )POOR ( ) UNKNOWN CATS?--------------------------------------------( )GOOD ( )FAIR ( )POOR ( ) UNKNOWN CHILDREN UNDER 5 YRS?--------------( )GOOD ( )FAIR ( )POOR ( ) UNKNOWN OTHER CHILDREN?-----------------------( )GOOD ( )FAIR ( )POOR ( ) UNKNOWN STRANGERS?-------------------------------( )GOOD ( )FAIR ( )POOR ( ) UNKNOWN IF POOR, PLEASE EXPLAIN DOES YOUR DOG DISPLAY SIGNS OF FOOD OR FEAR AGGRESSION? ( )NO ( )YES IS YOUR PET PROTECTIVE OF ITS TOYS OR POSSESSIONS?( )NO ( )YES DOES YOUR PET DISPLAY ANY UNUSUAL BEHAVIORAL PROBLEMS? (ex: self-mutilation, hyperactivity, tail chasing, ) OR FEARS (ex. thunderstorms, other dogs, cats, etc?)( )NO ( )YES IF YES, PLEASE EXPLAIN: HAS YOUR PET HAD ANY OBEDIENCE TRAINING? ( )NO ( )YES HOW DO YOU CORRECT YOUR PET WHEN IT DOES SOMETHING WRONG? ( )YELL( ) HIT IT ( )CONFINE TO CRATE ( )BANISH TO BACK YARD ( )DON'T CORRECT ( ) IF OTHER, PLEASE EXPLAIN_ IS YOUR PET CRATE TRAINED? ( )NO ( )YES HOW LONG HAVE YOU LEFT YOUR PET IN A CRATE AT ONE TIME?HOW DID IT RESPOND? ARE THERE STAIRS IN YOUR HOME? ( )YES ( )NO IF YES, DOES IT CLIMB THEM?WHERE DOES YOUR PET SLEEP? HOW DOES IT SPEND ITS DAY? DOES YOUR PET TRAVEL WELL IN A CAR? ( )NO ( )YES WHAT BRAND OF DOG FOOD DO YOU FEED YOUR PET? _HOW MUCH?FEEDING TIMES? WHAT IS YOUR DOGS FAVORITE TREATS? DO YOU EXERCISE YOUR DOG? ( )YES ( ) NO IF YES, HOW? HOW OFTEN? DO YOU BATHE YOUR DOG? ( )YES ( )NO ( ) PERFORMED BY GROOMER IF YES, HOW OFTEN?HOW? DOES YOUR DOG ENJOY IT? ( )YES ( )NO WILL IT LET YOU CUT IT'S NAILS? ( )YES ( )NO ( )PERFORMED BY VET LIST OF POSSESSIONS TRANSFERRED WITH PET: MY DONATION FOR ACCEPTING MY PET CC INFORMATION EXP DATE PLEASE REMEMBER IT COSTS TO BOARD, FEED AND RETRAIN YOUR PET ...TRY TO MAKE A MONTHLY DONATION IF POSSIBLE-- OWNERS AFFIDAVIT I HEREBY DECLARE THAT I AM THE LEGAL OWNER OF THE ABOVE DACHSHUND OR DACHSHUND MIX AND WILLINGLY SURRENDER THIS ANIMAL TO KENTUCKY DACHSHUND RESCUE FOR THE PURPOSE OF FINDING IT A NEW PERMANENT HOME. I UNDERSTAND I AM RELINQUISHING MY PRESENT AND FUTURE RIGHTS AND CLAIMS TO THIS ANIMAL AND ITS POSSESSIONS LISTED HEREIN WHICH ARE BEING SURRENDERED ALONG WITH THE ANIMAL TO ENSURE THE ANIMAL'S CONTINUED HAPPINESS AND WELFARE. I UNDERSTAND THAT I MAY NOT BE PROVIDED WITH INFORMATION ABOUT THIS ANIMAL'S WHEREABOUTS AFTER ITS SURRENDER, BUT AM ASSURED IT WILL RECEIVE A LOVING AND PERMANENT HOME AND WILL NOT BE USED FOR ANY BREEDING PURPOSE OR MEDICAL OR SCIENTIFIC EXPERIMENTATION. I FURTHER ATTEST TO THE BEST OF MY KNOWLEDGE, THIS ANIMAL HAS NO PHYSICAL OR EMOTIONAL PROBLEMS OR HANDICAPS THAT WOULD MAKE IT UNSUITABLE AS A FAMILY PET. ALL STATEMENTS MADE HEREIN BY ME ARE TRUE AND COMPLETE TO THE BEST OF MY ABILITY. SHELTER SURRENDER/SHELTER NAME_ OFFICER ON DUTY OWNER surrender/ SIGNATURE PRINTED NAME DRIVERS LICENSE#SS#** THERE MAY BE A WAITING LIST TO ACCEPT YOUR PET AND IF NOT UTD ON SHOTS OR NEUTERED A FEE TO HELP OFFSET THE COSTS TO PROVIDE THOSE FOR HIM* KDR OFFICIAL USE ONLY DATE OF SURRENDER-TIME KDAR MEMBER ADDRESS HOME PHONEEMAIL