First Name*

Last Name*

Email*

Home Phone

Cell Phone

Dog's name *

Breed

Dog's gender*
Choose one: Male/Intact Female/Intact Male/Neutered Female/Spayed Male/unknown Female/unknown

Dog's age*

Is the dog microchipped?*
Choose one: Yes No

How long have you had this dog?*

What is the reason for surrendering this dog?*

What would need to happen for you to keep this dog?

Where did you get this dog?*

If this dog was adopted from CCRC, please provide the name of the adopter who filled out the adoption paperwork (if different from above).

What city do you (and the dog) live in?*

Please list the ages of each person under 18 living in your home.

Please list any other pets in the home.

Describe your household:*
Choose one: Quiet/Calm Active/Noisy

Describe your dog's behavior around Children. Check ALL that apply.

Describe your dog's behavior around strangers. Check ALL that apply.

Describe your dog's behavior around cats. Check ALL that apply.

Describe your dog's behavior around other dogs. Check ALL that apply.

What other information should we have about the dog's interactions with animals or people?

Has the dog seen a veterinarian on a regular basis?

Name of your veterinarian

Please list any past or current medical conditions this dog has had:

Please list any medications and/or foods that have been recommended or prescribed for this dog:

Describe the dog's personality (check ALL that apply):

Please list any commands or tricks your dog knows:

Check any of the following that frighten the dog (check ALL that apply):

Has the dog ever growled at/snapped at/nipped/bitten a human?*

If yes to the above, please describe the incident:

If the dog has nipped or bitten, was the skin broken? If so, how badly (scratch, puncture, stitches needed, ER visit)?

Are there any places on the dog's body he/she does not like to be touched/brushed/petted? If so, please describe.

Where does your dog live (indoor, outdoor, etc.)? Please describe.*

How does the dog play with other dogs (check ALL that apply)?

What is the dog's favorite thing to do?

How does your dog do, regarding pulling, on leashed walks?
Choose one: Great Pulls a little Pulls very hard Unknown

Can the dog be left alone in the house for 8 hours a day without issues?*
Choose one: Yes No n/a

Where does the dog stay when no human members of your family are home (loose, crate, certain room, outside, etc.)?*

How is the dog kept in your yard (wood fence, chain link fence, tie out, invisible fence, etc.)?*

Does the dog escape from the yard?*
Choose one: Yes No

Describe the dog's house training habits (check ALL that apply):

What is the dog's best quality?*

What is the dog's worst quality?*

Please list anything else you think we should know about the dog to help place him/her in the right home:

I am seeking to surrender ownership of the dog described above to CCRC. By placing my name below, I agree that if CCRC is able to take the dog, I give up all claim to this dog and allow CCRC to make all future decisions about the care and placement of this dog.

Please Type Name (this will serve as your signature)*