We understand that giving up your dog is a difficult decision, but we realize that in making this choice, you have your dog’s best interests at heart.
When filling out the Owner Surrender Form please provide as much information as possible. Above all, be honest. We understand your dog may not be perfect, but the more we know the better we are able to find the perfect new home for your dog.
First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
County*
Country
Email*
Home Phone*
Work Phone x
Cell Phone
Alt Email*
Is this an outside dog?
Best time to call:*
How often do you check for calls?
By what date must you surrender the dog?*
Are you the sole legal owner of the dog?
Dog's Name:*
Dog's age:*
Gender:* Choose one: Male Female No preference
Is the dog spayed or neutered?* Choose one: Spayed Neutered Intact
Color:*
Weight:*
Where did you get this dog?
How long have you had him/her? *
Is it a purebred Golden Retriever?
Is this a GoldenDoodle
If dog is neither a Golden Retriever nor GoldenDoodle, what breed is the dog?
Do you have AKC papers?
Is the pedigree available?
Is the dog microchipped?
If microchipped, what is the number?
Are vaccinations current? * Choose one: Yes No Unknown
If yes, which vaccinations are current?
Is dog on heartworm preventative?
If yes, what type of preventative?
When was last heartworm preventative given?
When was last flea/tick preventative given?
Has this dog ever had a seizure?
If yes, how often does he/she have seizures?
Does the dog have any ear problems/recurring infections?
Does the dog have any orthopedic problems (Hip dysplasia, arthritis, stiffness)?
If yes, what sort of problems?
Does he/she have any skin problems?
Does the dog have any allergies?
If yes, what sort of allergies?
Does he/she have any other medical conditions?
If yes, what conditions?
I understand that GRRSWF will make every effort to find a loving home for my dog and grant my permission to contact the medical service provider named below and hereby grant permission for the release of all records and information in their possession. It is the owner’s responsibility to ensure that GRRSWF has a copy of the dog’s records prior to, or at the time of, the physical surrender. Please note that GRRSWF will not take possession of the dog unless vet records are provided. Please netter the following information: Veterinarian Name: Telephone Number: Address: City: State: Zip:*
What is the dog's disposition?
Is the dog confident or shy?
Can you take food away?
Can you take toys away?
Can you take bones away?
Does the dog dig?
Does the dog chew?
Does the dog escape from the yard or house?
Does the dog run away?
Does the dog jump over or climb fences?
Does the dog jump on people?
Does the dog steal food or items from the counters or tables?
Does the dog swim?
Does the dog ride well in cars?
Is the dog housebroken?
Is the dog crate trained?
Does the dog get along with other dogs?
Does the dog get along with cats?
Does the dog get along with other animals?
Is this dog aggressive to other dogs?
If yes, what did the dog do to make you think it didn't like the other dog?
Is the dog possessive over the food dish?
Does the dog accept strangers?
Does the dog accept men?
Does the dog accept women?
Does the dog like to chase bikes or cars?
Does the dog get along with children?
Has the dog ever lived with children?
If yes, for how long?
What were the children’s ages?
Is there anywhere the dog does not like to be touched?
How did the children treat the dog?
If yes, where?
Is the dog afraid of thunderstorms?
If yes, what does this dog do during a thunderstorm?
Has the dog ever growled at a person?
If yes, please describe the circumstances
Has the dog ever snapped at a person?
Has the dog ever bitten a person?
Has the dog ever growled at or bitten another animal such as a dog or cat?
Has the dog ever displayed any other signs of aggression?
If yes, please describe:
Does the dog like to grab your arm or clothes (mouthy)?
If yes, please explain:
What does the dog dislike?
What is the dog afraid of?
Has the dog been to obedience school?
If yes, which obedience school?
Does the dog know any commands? Please list:
Please describe your training methods:
Have you ever disciplined this dog when he/she has done something wrong? Please describe:
Has the dog ever lived with other dogs?
Has the dog ever lived with cats?
Is this dog used to being home alone during the day?
If yes, how many hours on average?
Does the dog have separation anxiety?
If yes, how do you handle it?
How do you exercise the dog? How often?
What kind of food is the dog eating now?
How often is he/she fed?
Is the dog on any vitamins or supplements?
If yes, please list:
Why are you giving up this dog? (Please be as detailed as possible)
What are the dog's bad points? Please be as honest as possible - we know he/she may not be perfect but the more we know about him/her, the better we are able to select a suitable foster home and then the very best permanent home for him/her:
What are the dog's good points? Again, the more we know about him/her the easier it is to find the perfect home for him/her.
Is there anything else that you would like us to know about the dog?
As the the owner or the fully appointed agent of the dog described in this Owner Surrender Form, you do hereby affirm, acknowledge, warrant and represent that all information contained in this profile is true and correct to the best of your knowledge and belief. Should any information set forth be discovered to be false, untrue or misleading in any respect at any time, then Golden Retriever Rescue of Southwest Florida, Inc (GRRSWF) shall have the right to (1) rescind this agreement and require the owner to take the dog immediately back into his/her possession, and/or (2) require the owner to pay all costs incurred in the care, placement or disposition of the dog. Do you understand and agree?
Should any of the information set forth in this document be discovered to be false, untrue or misleading in any respect at any time, then owner agrees to indemnify and hold GRRSWF 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. Do you understand and agree?
I understand that GRRSWF will utilize the information contained in this form to assist in selecting an appropriate Foster Home and Adoptive Home. I understand that I will be held liable for any and all claims, suits, damages, liabilities and costs (including reasonable attorney fees) related to or in any manner connected with this dog that is a result of any false, untrue or misleading information provided in this form that therefore results in the dog being placed in an inappropriate home, situation or environment.
I understand that GRRSWF 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 in the Owner Surrender Form and hereby grant permission for the release of all records and information in their possession.
I understand that GRRSWF will have full ownership of the dog effective immediately upon surrender and that I will not be permitted to see or visit it at any future date. I understand that I may contact GRRSWF periodically to inquire as to the dog’s wellbeing, but that I will not be informed of the dog’s whereabouts or provided with any identifying details regarding the dog’s foster or adoptive home.
THIS IS INTENDED TO BE A LEGALLY BINDING AGREEMENT. IF NOT FULLY UNDERSTOOD SEEK THE ADVICE OF AN ATTORNEY PRIOR TO AGREEING.
I HEREBY RELINQUISH OWNERSHIP OF THE ABOVE-MENTIONED DOG TO GOLDEN RETRIEVER RESCUE OF SOUTHWEST FLORIDA, INC.
Golden Retriever Rescue of Southwest Florida
