Surrender Form

We understand that sometimes circumstances change. Please complete this form as thoroughly as possible — accurate information helps us find the best home for your dog. All fields marked with * are required.

About You

Full Name

Best Time to Contact

MorningAfternoonEveningAnytime

Home Address

City

State

Zip Code

Email Address

Cell Phone

Home Phone

Work Phone

# of people in your household

Genders & Ages of household members

Are you the dog's first owner?

YesNo

Dog 1

Name

Breed

Color / Markings

Weight (approximate)

Date of last vet visit

Willing to provide veterinary records?

YesNo

Surrendering more than one dog?

No Yes - 2 dogs Yes - 3 or more

Dog 2

Name

Breed

Color / Markings

Weight (approximate)

Additional Dogs

List additional dogs (Name / Breed / Age / Gender / Spayed-Neutered / Color / Weight)

Dog History & Background

Is the dog microchipped?

Yes No Unknown

Microchip Number(s)

Is the dog currently licensed?

YesNo

Food (brand / type)

Amount per feeding

Feeding frequency

Treats?

Exercise per day

How long is the dog home alone in a typical day?

Where does the dog sleep at night?

Where does the dog stay during the day?

When everyone leaves, is the dog's behavior problematic?

Yes No

Describe the dog's behavior when everyone leaves:

Is the dog housebroken?

YesNoMostly

Does the dog alert to go outside?

Yes No

If yes, how does the dog alert?

Is the dog crate trained?

YesNo

Is the dog leash trained?

YesNo

Trained on an in-ground fence?

YesNo

Equipment used when walking (check all that apply):

Collar Harness Other

Collar type (if applicable)

Other walking equipment description

Has the dog received any obedience training?

Yes No

If yes, what kind of training?

Commands the dog knows:

Under what circumstances is the dog likely to bark?

Behavior & Temperament

Your dog gets along with (check all that apply):

Strangers Children under 10 Male dogs Female dogs Cats Livestock Birds

Your dog chases (check all that apply):

If other, please describe:

Your dog growls, barks, or nips if you approach their (check all that apply):

Other (if applicable):

Please describe this behavior:

Describe your dog's experience with, and behaviors around, children:

Describe your dog's behavior around other dogs:

Has the dog ever bitten or snapped at a person or animal?

Yes No

How many times?

Please describe the incident(s) in detail:

In what circumstances has your dog become aggressive?

Behavioral issues (check all that apply):

Excessive barking Destructive chewing Jumping on people Pulling on leash Separation anxiety Resource guarding Fear/anxiety Escaping yard/house None

General description of your dog's behavior and personality:

Veterinary Information

Veterinarian Name / Practice

Vet Phone

Vet Address

Vet City

Up to date on vaccinations?

YesNoUnknown

Date of last heartworm test

On heartworm prevention?

YesNo

Any current medical conditions?

Yes No

Please describe current medical conditions:

Any known allergies?

Yes No

Please describe known allergies:

Any medications? If yes, please list:

Placement & Preferences

Does your dog require a fenced yard?

Yes No

If yes, type of fence required (check all that apply):

Physical fence In-ground fence

Does the dog like to ride in the car?

YesNo

What are your dog's favorite things?

What equipment/possessions will you send with your dog to its new home?

Reason for Surrender

Please describe your reason in more detail:

Have you tried any solutions to keep the dog?

Yes No

What solutions have you tried?

Have you tried to find a home for the dog yourself?

Yes No

If yes, please describe:

Any preferences for the new home?

Is there anything else we should know about your dog?

Acknowledgment

I confirm the information provided is accurate to the best of my knowledge. I understand that Michigan Standard Poodle Rescue will make every effort to place my dog in a loving home, but cannot guarantee placement. *