EmailMe Form - Owner Surrender Contract

Owner Surrender Contract

The Long Dog Retreat Inc. Owner Surrender Form

We are sorry that you have had to make the decision to surrender your dog. We DO ACCEPT owner surrenders based on AVAILABLE SPACE. Our spaces are very limited and are based on a quota system. We have a certain number of spaces available for senior/special needs dogs, adult dogs, youths and puppies. IF we have a space available, our Intake Specialist will contact you and arrange for you to bring the dog to our rescue. We do NOT TRANSPORT dogs, so you will need to make arrangements to get your dog to one of our volunteers.
The more information you can give us about your pet, the easier it makes it for us to get him/her adopted.

Owners Name
First Last
Dog 1 Name
First Last
Dog 2 Name
First Last
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Email
Phone
### - ### - ####
Dog 1 Birthdate
If you do not know/put your best guess.
Dog 2 Birthdate
If you do not know/put your best guess.
Dog 1 Breed
Dachshund/Mix Breed
Dog 2 Breed
Dachshund/Mix Breed
Dog 1 Neutered/Spayed
Yes
No
Dog 2 Neutered/Spayed
Yes
No
Up to date on Rabies?
Yes
No
Do you have a rabies tag or certificate?
Yes
No
Can medical records be provided?
Yes
No
Has this dog had monthly heartworm medication?
Yes
No
Has this dog bitten anyone in the last 10 days?
Yes
No
If Yes, please explain
Who is your dog's veterinarian? At which clinic (Name, address and phone #)?
When did your dog last get shots? Rabies/etc
Why do you need to surrender your dog?
Has this dog had any surgeries besides spay/ neuter?
Does your dog have any medical problems that you know of?
How long has this dog lived with you?
Where did you get your dog?
Where did you leave your dog when he/she was alone?
Would the dog run away if unleashed?
Where does your dog sleep at night?
Do you trust your dog loose indoors, unsupervised? If no, why?
Do you consider this dog: High energy, Medium energy or Couch potato?
How does your dog tell you he/ she needs to go potty?
What brand/ type of food does the dog eat?

Is he/she fed table scraps?
What types of animals has your dog lived with? (please include gender, species, etc.)

Please describe how they got along.
What ages of children has your dog lived? Visited with?
Any comments about your dog with children?
What are your dog's shining qualities?
Does your dog travel well in the car?
Is there anything that makes the dog anxious or nervous?

Separation anxiety?
Has your dog been vaccinated within the last year? Which?
Has your dog ever nipped at anyone? If yes, who?

If yes, under what circumstances?
Is there any part of your dog's body that he/she doesn't like touched?
Has your dog ever killed a cat or any other animal?
Is your dog aggressively protective of his/her: food, home, yard, family, bed, and car?

Yes No

Food

Home

Yard

Family

Bed

Car
Please list any other pertinent information that may be useful to the foster parents / parents:
In your opinion; what would be the best home situation / environment for the dog?
Please upload a picture of your dog.
Please upload a picture of your dog.
Donation
The Long Dog Retreat Dachshund Rescue is an 501c(3) tax exempt non profit organization.
All dogs are fully vetted, neutered and micro-chipped before adopted. We have a suggested donation of $20.00 for dogs that require no shots/neuter.
$30.00 for those that do. If you are able to donate, we appreciate it. If you are unable to donate, we understand.
Yes I would like to donate.
No I am unable to donate at this time.
Veterinary Office Name
First Last
Name of Veterinary office.
Veterinary Office Phone Number
### - ### - ####
The number of the last veterinarian this dog has seen.
Before surrendering my dog I affirm it has been treated for fleas. The Long Dog Retreat CANNOT accept any dogs into rescue that have an active flea infestation. Acceptable flea treatment is with:
A Seresto Collar
A Capstar Pill
A topical solution containing either Fipronil or Imidacloprid.Dinotefuran, or Selamectin.
Yes
No
I authorize The Long Dog Retreat to contact my veterinarian to receive information about the dog listed on this form.
Yes
No
My dog has never been to a veterinarian.
If you do not authorize The Long Dog Retreat to contact your vet, we CANNOT accept the dog without a physical copy of the dogs medical records.
Signature

By signing this document I acknowledge that all of the information is true and complete to the best of my knowledge. I am the legal owner of this dog and authorized to re-home/relinquish this dog to The Long Dog Retreat Dachshund Rescue. I have not signed any contracts requiring me by law to return this dog to any breeder or other rescue organization .I also acknowledge that by surrendering my dog to The Long Dog Retreat I am relinquishing my ownership. The Long Dog Retreat will do its best to keep bonded dogs together but I understand that in some instances bonded dogs must be separated in order to find acceptable homes. I understand that The Long Dog Retreat Inc. is a no kill facility but in the case of severe illness, pain or extreme aggression my dog may be humanely euthanized.
By signing this agreement I release, holds harmless and forever discharge The Long Dog Retreat Inc any and all claims arising from fostering this rescue dog. *
Clear
Signature is required but please do not sign until all of your questions/concerns are answered. You can save this form and come back to sign later if needed. You can sign with your mouse.

	Yes	No
Food
Home
Yard
Family
Bed
Car