Surrender a Dog Please note, this form is designed to help you provide as much information to us about your dog as possible. At the point of hand over, you will be expected to sign a printed version of this form. Todays date Dogs Name Age (years and months if possible) Breed Sex malefemale Spayed/Neutered yesno Microchipped? yesno Chip number Why are you surrendering this dog? Please give as much information as you can. How log have you owned the dog? How many homes has the dog had including the breeder? Where did you get the dog? Has the dog bitten a person in the last 10 (ten) days? noyes If yes, please give the date, place (city) and name of the person bitten Has the dog ever:- BittenScratchedLunged or attackedNone of these If yes, did a bite break the skin? noyes Were the police involved? noyes Please explain the circumstances Please give the name, address and phone number for the dog's veterinarian Is the dog current on vaccinations? noyes Please list any past or present injuries, treatment or other medical history Please check all of the following that describes the dog very activecouch potatobarks a lothowlsquietplayfulfriendlyshylikes to be touchedaffectionatefearfulindependentprotectivealways at your sideindoor dogoutdoor dognervoushouse trainedcrate trainedlikes menlikes womenworked livestockused for huntingseparation anxietydiggerjumps fences How high could your dog jump a fence? Has the dog lived with children? yesno If so, what ages? Would you recommend the dog live with children in the future? yesno Has the dog lived with cats? yesno Would you recommend the dog live with cats in the future? yesno Has the dog lived with other dogs? yesno If yes, please describe the other dogs Would you recommend the dog live with other dogs in the future? yesno What are the dogs favourite activities or objects? What does the dog dislike or fear? Where is the dog kept during the day? Where does the dog sleep at night? Does your dog travel well in the car? What type of food do you feed your dog? Is there anything else a future owner should know about this dog? my signature below certifies that I am the owner of, or have the authority to surrender to Cupcakes Rescue, the animal described above. I hereby relinquish all rights of ownership and any right to information on the disposition of said animal. I also authorise the release of any veterinary records regarding the animal. I certify that to the best of my knowledge, I have disclosed all information about the animal concerning health, behaviour, history and anything else that may affect the safe placement of the animal in a new home and that all statements made above are true and correct. Signature Date Please print full name Please provide the best phone number to contact you on First line of your Address Postal Town County Postcode Your Email (required) I hereby acknowledge that I have been notified of and fully understand the following conditions of my relinquishment of this animal:- Pupcakes Rescue shall have sole and exclusive legal right to make all outcome decisions and take all actions deemed appropriate Pupcakes Rescue are under no obligation to communicate the outcome of the animal to you or any other party, however you may see updates of the dog on our Facebook page or website Pupcakes Rescue spends an average of £450 on food, shelter, medical and other care for each animal we receive. If you are able, please consider making a donation to help us care for your dog. Thank you!