Relinquishment Form

* Required fields

Name *

E-mail Address *

Address *

City *

Zip Code *

Home Phone Number *

Cell Phone Number *

Name of your dog *

Breed or Primary Breed Mix *

Aproximate age of dog *

Apriximate size of dog (in pounds) *

Sex of your dog *

Male Female

Spayed or Neutered? *

Yes No

Is your dog potty trained? *

Yes No

Why are you giving up your dog? Please be specific... *

Are you the legal owner of this dog? *

Yes No

If not, please explain...

Is your dog good with cats? *

Yes No Unknown

Has your dog been living with children? *

Yes No

If yes, what ages?

Is your dog good with women? *

Yes No

Is your dog good with men? *

Yes No Some

How is your dog when he/she meets strangers? *

Friendly Timid/Shy Aggressive Obnoxious

Is your dog good with other dogs? *

Yes No Some

Where was your dog obtained? *

Rescue Friend Pet Shop Pound/Shelter Breeder Gift Other

If rescue, which one?

If other, please explain...

How long have you had your dog? *

Does your dog have ANY health issues? *

Yes No

If yes, please explain...Please also include current treatment. *

Has your dog been an... *

Indoor Pet Outdoor Pet Indoor/Outdoor Pet

Your dog eats... *

Dry Food Only Wet Food Only Dry/Wet Both

Brand of Dog Food *

Quantity of food and how often? *

Is your dog crate trained? *

Yes No

Where does your dog currently sleep? *

Bed with you Outside In garage Where he/she wants in the house Crate

How much time does your dog spend alone during the day? *

Is your dog destructive when left in the house, alone? *

Yes No Sometimes

Where does your dog stay when you are not home? *

Inside Outside Indoors/Outdoors (Doggie Door)

Does your dog have any separation anxiety? *

Yes No Sometimes

If "yes" or "sometimes", please elaborate and give details.

When left alone, does your dog... *

Doesn't care Whines/Cries Barks/Howls Destructive

What games does your dog enjoying playing? *

Frisbee Fetch Tag Tug-o-War Ball None: Couch Potato

Has your dog ever bitten or shown any aggressive tendencies: *

Yes No

If yes, to whom, and under what circumstances (please be honest, you will be liable if this dog is placed and bites someone and you were aware that the dog had a history of biting)

Is your dog possessive of toys, food, or his/her people: *

Yes No

How does your dog react if you approach his toys, food, etc.: *

Has your dog had obedience training, even a basic class: *

Yes No

How does your dog respond to commands: *

Excellent Good Fair Poor When HE/SHE wants to...

What is the best way to get your dog to listen/obey: *

Praise Treat Correction Firm Voice

Are you able to foster your dog until a new home can be found? *

Yes No Possibly, depends on time frame.

If "yes" or "possibly", please give us the latest date you can keep the dog...

All statements made above are truthful to the best of my knowledge. I understand that I may retain liability if I have knowingly misstated the truth about my dog and he causes injury to humans, other animals, or property. I also understand that I am not entitled to any form of compensation for this dog. *

Accept Do not accept

I understand that Love 4 Canines will need the following upon transfer of dog:A copy of dog's medical records, including spay/neuter certificate, rabies certificate, and proof of current DHLPP shot. *

Yes No

I have read and agree to the Privacy Policy *