Middleburg Heights Animal Foundation

Canine Surrender Questionnaire

Today's Date:

Full Name:

Street Address:

City, State, Zip Code:

E-mail:

Phone Number:

Best Time to Call:

Dog's Name:

Breed:

Dog's Age:

Dog's Sex:

To enable us to find the best possible home for this dog, please fill in the information below as completely and accurately as possible.

Why are you giving up this dog?

How long have you owned this dog?

Where did you get this dog?

How many owners has this dog had?

What other types of pets did this dog live with?

Please describe any conflicts with this dog and the other pets:

List the ages of any children in the household:

Please describe any conflicts this dog had with the children:

How many hours a day was this dog left alone?

Where did this dog spend most of his time?
  Always Outside
  Mostly Outside
  In Garage
  Outside unless we were home
  In a Crate
  In or Out at Will
  Always Inside

Please describe how the dog reacted to being left alone.

How often does this dog urinate or defecate in the house?

What form of daily exercise did this dog receive?

How did you confine this dog to your property?

Do you have...?   Fence
What type?     How high?

  Kennel
What size?     Completely enclosed?

  Chain or Tie Out
How long?     Where?

  Invisible Fence
  Never outside off leash or unsupervised
  Did not confine - Dog would always come home

How often did your dog escape confinement? How?

What type of obedience training has your dog had?

What commands does your dog respond to?

Have you ever consulted a trainer or behaviorist on any problem concerning this dog?
  Yes
  No

If yes, what kind of problems?

How many times did you consult them?

Has this dog ever bitten or snapped at anyone?
  Yes
  No

If yes, describe the incident:

Describe any problems this dog has had with the following:
Children:

Other Dogs:

Cats or Wildlife:

Strangers:

Other:

Is this dog overly protective of any of the following? (please give examples)
Food:

Toys:

Family Members:

Property:

Car:

Other Pets:

What types of situations / things make your dog bark?

Has their barking ever created a problem?

What form of discipline or correction do you use with this dog?

How does the dog react to discipline / correction?

Who is your dog's veterinarian or veterinary clinic?

What kind of health problems has this dog had?

What types of medications has it used?

What type of flea control is your dog currently using?

What type of heartworm medication is your dog currently on?

Date of last dose?

Is this dog on a special diet?
  Yes
  No

If yes, what type?

Describe your dog's idea of a perfect day:

It is understood that Middleburg Heights Animal Foundation does not buy or pay for dogs; but surrender donation is required to help cover medical care, housing, and feeding.

$75.00 for canines up-to-date with ALL vaccinations, rabies shot, and has been spayed or neutered. (Vet records required)
$100.00 for canines that need vaccinations and rabies shot; but has been spayed or neutered. (Vet records required)
$125.00 for canines up-to-date with vaccinations, rabies shot; but needs to be spayed or neutered. (Vet records required)
$150.00 for canines that need vaccinations, rabies shot, and to be spayed or neutered.

We also suggest that owners surrendering a dog donate the dog's leash, collar, crate, food/water bowls, toys, grooming items, bags of the dog's food, copies of their medical records and anything else that the owner will no longer need due to the surrendering of the pet. This is a service to help place dogs in new homes when their present owners can no longer keep them.

Please read and sign the following:

I, , hereby make available for adoption, the dog, named , to Middleburg Heights Animal Foundation. I certify that I am the owner of this dog, free and clear of all other interests. I certify that this dog is not possessed of any dangerous or vicious tendencies, and that I have not willfully concealed information about the dog that much indicate such tendencies. The information I have provided about this dog is true and complete. I hereby forever release, discharge, and agree to hold harmless and indemnify Middleburg Heights Animal Foundation, its Board of Directors, its members, officers, and agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above named dog. I further understand that in signing this agreement I surrender all rights to ownership of this pet immediately and permanently. I authorize any veterinarian this pet may have seen in its lifetime to release any and all medical records to MHAF.

Signature: Date:

By typing your name in the signature box above you certify that the information included in this agreement is true and accurate to the best of your knowledge and that you are the individual requesting to surrender the above named pet to Middleburg Heights Animal Foundation and its foster homes.