First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone*

Cell Phone

Alt Email

Has your dog bitten any human or other animal in the last 10 days?

Has your dog ever bitten any human or other animal and drawn blood?

Dog Name:*

Dog Breed/s*

Color of your dog?*

Is your dog male or female?*

Dogs BirthDate*

Is your dog spayed or neutered?*

How much does your dog weigh?*

Why are you wanting to surrender your dog?*

Is your dog house trained?

Does your dog know any tricks? *

Does your dog like cats?

Does your dog like children?

Does your dog like other dogs?

What food does your dog eat?*

Please describe your dog's likes, dislikes, and personality.*

Does your dog suffer from anxiety or have any specific fears?*

Is your dog destructive? Explain:*

Is your dog crate trained?

Does your dog escape fenced yards or home?*

Please complete this form to help us find the safest and most appropriate home for your dog. Detail anything that you think will help your dog find the best home for him/her. Undesirable behaviors and medical issues do not necessarily create problems in placement, however, NOT disclosing those problems does. Dishonest or incomplete answers can undermine the safety and happiness of both your dog and the new adopting family. If there is anything on this form that you are unclear about or that you are uncomfortable in answering for any reason, please email Carol at rescue.me.pa@gmail.com .*