Surrender Application – Golden Treasures Rescue

SURRENDER INTAKE PROFILE

Surrender

Thank you for taking the time to thoroughly fill out this form. The information provided by you is important and allows us to make the best possible decision when rehoming your Golden.

Dog's Name

Owner

Street Address

City

State

Zip Code

Phone

Cell Phone

Is your dog male or female?

Is your dog spayed/neutered?

Age of your dog?

Date of Birth of your dog?

Weight of your dog?

Color of your dog?

Is your dog a purebred Golden?

If No, please identify mixes

Where was your dog purchased/obtained from?

How Long have you had your dog?

Where is your dog currently housed?

Do you have AKC papers on your dog?

Is your dog micro chipped?

Company brand name

ID#

Veterinary Information

Name of Clinic

Name of Veterinarian

Clinic Phone Number

Fax

Please call your Veterinarian to release all medical information on your dog to Golden Treasures

Are Vaccinations up to Date?

Date vaccinations given

Has your dog been heartworm tested

Date of last heartworm test

Currently on heartworm prevention medication?

Name of heartworm medication

Date Last Given

Is your dog currently on any medications other than heartworm?

If yes, Name of med, dosage, frequency given

Does your dog have allergies?

If yes, what type and how is it being treated

Does your dog have seizures?

If, yes, date of last seizure

How often?

What treatment is dog receiving for the seizures?

Temperament

Briefly describe your dog's temperament

Good with Kids?

Ages

Housebroken?

Good alone?

Destructive

Obedience trained?

Crate Trained

Comes When Called?

Leash Trained

Has a fence?

Type?

Will dog run away if it gets loose?

Chase cars?

Good with cats?

Like other dogs?

Accustomed to being alone?

How long?

Trustworthy in house alone?

Afraid of storms/fireworks?

If yes, what is behavior like?

Rides well in car?

Exercised frequently?

Exercised How?

What is your dog's energy level?

Where does dog sleep?

Food/Toy aggressive?

If dog is Food/Toy aggressive, please explain

Does your dog jump on people?

Does your dog do any mouthing?

Has your dog ever snapped/growl at people?

If dog has snapped/growled please the explain situation

Has your dog ever bitten anyone?

If dog has bitten when was it?

If dog as bitten please explain the circumstances

What food do you feed?

How much food?*

How often is dog fed?

Does you dog have behavioral problems?

Explain behavioral problems

Does your dog have any medical problems? (chronic ear infections, hot spots, tumors, etc.)

If yes, please explain medical problems

Reason for relinquishment?

OWNER AGREEMENT

THE UNDERSIGNED, BEING THE OWNER OR THE DULY APPOINTED AGENT OF THE ABOVE-DESCRIBED DOG, DOES HEREBY AFFIRM, ACKNOWLEDGE AND WARRANT AND REPRESENT THAT ALL INFORMATION CONTAINED IN THIS PROFILE IS TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF. SHOULD ANY OF THE INFORMATION SET FORTH BE DISCOVERED TO BE FALSE, UNTRUE OR MISLEADING IN ANY RESPECT AT ANY TIME, THEN GOLDEN TREASURES SHALL HAVE THE RIGHT TO (1) RESCIND THIS AGREEMENT AND REQUIRE OWNER TO TAKE THE DOG IMMEDIATELY INTO HIS/HER POSSESSION AND/OR (2) REQUIRE OWNER TO PAY ALL COSTS INCURRED IN THE CARE, PLACEMENT OR DISPOSITION OF THE DOG. FURTHER, SHOULD ANY OF THE INFORMATION SET FORTH IN THIS DOCUMENT BE DISCOVERED TO BE FALSE, UNTRUE OR MISLEANDING IN ANY RESPECT AT ANY TIME, THEN OWNER AGREES TO INDEMNIFY AND HOLD GOLDEN TREASURES HARMLESS BY, FROM AND AGAINST ANY AND ALL CLAIMS, SUITS, DAMAGES, LIABILITIES AND COSTS (INCLUDING REASONABLE ATTORNEY FEES) RELATED TO OR IN ANY MANNER CONNECTED WITH THIS DOG.

I understand that Golden Treasures Golden Retriever Rescue, Inc. will make every effort to find a loving home for my dog and grant my permission to contact all of the medical service providers named above and hereby grant permission for the release of all records and information in their possession.

I HEREBY RELINQUISH OWNERSHIP OF THE ABOVE-MENTIONED DOG TO GOLDEN TREASURES. IF, FOR ANY REASON, I DO NOT TURN MY DOG OVER TO GOLDEN TREASURES ONCE I HAVE ASKED FOR THEIR HELP, I UNDERSTAND THAT THERE WILL BE A $50.00 ADMINISTRATION FEE, WHICH I AGREE TO PAY. GOLDEN TREASURES' RESPONSIBILITY FOR THE CARE, PLACEMENT OR DISPOSITION OF THE DOG, OR FOR COSTS INCURRED, WILL NOT BEGIN UNTIL THE DOG IS IN THE POSSESSION OF GOLDEN TREASURES.

By typing your name below, you acknowledge that your electronic signature constitutes a legally binding agreement, equivalent to a handwritten signature. Do you agree?

Digital Signature

Date

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SURRENDER INTAKE PROFILE

Veterinary Information

Temperament

WAYS TO REACH US

Golden Treasures Rescue

PO Box 434, Bath, OH 44210

EMAIL: dogs@goldentreasuresrescue.org

NOTICE