Owner Release Form
Owners Name:
Street Address:
City:
County:
E-mail:
State:
Home Phone:
Zip/Postal Code:
Referred by:
Today's Date:
Dogs Formal Name:
Dogs Nickname:
Dogs Breed:
AKC Number:
If your dog is not registered, please leave blank
--------------------------------------------------------------------------Other Information
Sex: Male Female
Color:
Weight:
Spayed/Neutered: Yes No
If not spayed or neutered, why not?:
Age of Dog:
Age at Purchase:
Date Available / /
If this dog is a stray, how long have you had it in your possession?
Dog's Breeder:
Breeder's Contact Information:
Have you tried to contact the dog's breeder? Reputable breeders always take responsibility for
the dogs they produce and usually want their dogs back if you cannot keep it, no matter what the
age of the dog is now.
____ Yes, we contacted the breeder.
What did they say?
____ No, we did not/cannot contact the breeder If no, why not?
The more we know about your dog, the better job we can finding the best possible home
for it. Please answer the following questions as completely and honestly as possible.
Current family includes (please give children's ages)
Do you have other animals? (type, sex, age)
Does your dog like:
Water (Swimming)
Cats
Other Dogs
Children
Baths
Car Rides
Brushed
Strangers
Trimmed
Elaboration on Likes/Dislikes
Is your dog:
Housebroken
Crate trained
Obedience trained
Food Aggressive (i.e. dog growls if you get near food/bones/toys)
Does your dog:
Chew
Bark
Jump on people
Dig
Come when called
Walk on lead
Does your dog know:
Sit
Stay
Heel
Down on command
Fetch
Can you leave him/her unattended in the house for long periods of time without him/her damaging
anything? Yes
No
Don't know
Any special training tricks?
If obedience trained, when and where?
Your Household activity level:
Quiet
Active
Very Active
Will your dog jump a
short (3ft) Fence
tall (6ft) Fence
How high is the fence the dog is kept in now?
doesn't try to get out
Do you have a local Veterinarian? Yes No
If yes, Vets:
Name:
Address:
Phone Number:
Vaccination Dates:
DA2PP
Rabies
Bordatella
Last Test Date:
Is the dog currently on heartworm preventative?
Preventative Type (Brand)
What day of the month do you give it?
Corona
Heartworm Preventative
Yes
No
Dog's feeding instructions
How many meals per day?
Amount each feeding:
Exercise/Potty Schedule:
How does dog let you know it's time to go outside?
Where is the dog during the day?
Where is the dog at night (where does dog sleep)?
Where does the dog eat and how much and what brand?
Describe the dog's general temperament:
Has this dog ever snarled or snapped? (Be honest)
Has this dog ever shown fear (of strangers, thunderstorms, etc.)?
Has this dog ever bitten a person or other dog? (Be honest)
Why are you unable to keep this dog?
Additional Comments:
If we feel your dog meets our adoption criteria, we will make arrangements for a volunteer to
evaluate your dog. During the evaluation, the volunteer will need to see the dog, any medical
records (please obtain a copy of them from your vet), AKC papers (if applicable) and any other
paperwork you feel is pertinent to your dog. Our Surrender Coordinator will later contact you
regarding our decision and expected date we could take the dog. When it is time to surrender
your dog, arrangements will be made for meeting a volunteer to surrender your dog. For safety
reasons, your dog must have a current rabies vaccination and rabies vaccination certificate at the
time of surrender (which is available through your vet's office). Copies of AKC and pedigree
information are useful if available. You may also donate any of your dog's food, bedding, crate,
bowls, collars, leashes, heartworm preventative, medication, etc. The volunteer will ask you to
sign a Wee Waggin surrender form, and collect the surrender fee of $100. Signing the surrender
form legally transfers ownership from you to Wee Waggin Rescue.
Unless the new adoptive family wishes, we will not release their name to the surrendering
families. We are very careful to screen our adopters and to match the right dog with the right
family. We provide after adoption counseling and will continue to visit the adoptive homes to
insure the care and well being of our dogs. In the rare event an adoption doesn't work out, the
adoptive family is required by contract to return the dog to our Rescue.
We will make every effort to place your dog in an environment that will make him or her happy
and will provide the dog with humane lifetime care. Be assured that once accepted into Rescue,
the dog will stay in rescue until a proper adoptive home is found.
RELEASE STATEMENT:
I am surrendering my dog, named, ___________________________to Wee Waggin Rescue and
wish Wee Waggin Rescue to place my dog and by my signature certify I am the legal owner of
the above dog and the above information is truthful, correct and complete. I certify the dog has
never bitten, growled or been aggressive towards a human. I understand any attempts to mislead
or falsify information will result in my dog being denied acceptance into Wee Waggin Rescue.
Surrender fees are: $100.00
(typing your name here is acting as your legal signature to this surrender
form)
Signature:
Date:
Warmly,
Kelly Chasnov
Eyetopian Optical
www.eyetopian.com <http://www.eyetopian.com>
239.405.0346