Dog Surrender Form

Collects the information a shelter or rescue group needs when an owner surrenders their dog, including behavior and health history.

Use this template

Name:

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Date:

Animal's Name:

Age

Breed

Upload a Picture of Your Dog

Max 10 MB per file

Behavior Assessment

Is your dog an escape artist?

Yes No

Does your dog struggle with confinement (in a crate)?

Yes No

Is your dog reactive to seeing people while on a leash?

Yes No

Is your dog reactive to seeing dogs while on a leash?

Yes No

Is your dog destructive in the home?

Yes No

Does your dog get anxious or carsick in the car?

Yes No

Is your dog potty trained?

Yes No

Is your dog protective of their food?

Yes No

Is your dog protective of their toys?

Yes No

Is your dog protective of their bed or space?

Yes No

Is your dog protective of other dogs in the household (if any)?

Yes No

Is your dog protective of their handler?

Yes No

Is your dog okay with children ages 0-2?

Yes No

Is your dog okay with children ages 3-5?

Yes No

Is your dog okay with children ages 5-8?

Yes No

Is your dog okay with children ages 8-12?

Yes No

Is your dog okay with children ages 12+?

Yes No

Has your dog ever lived with other dogs?

Yes No

Has your dog coexisted with dogs smaller than them?

Yes No

Has your dog coexisted with dogs larger than them?

Yes No

Has your dog ever injured another dog?

Yes No

Has your dog ever lived with cats?

Yes No

Has your dog ever injured a cat?

Yes No

Has your dog been fearful of children?

Yes No

Has your dog been fearful of men?

Yes No

Has your dog been fearful of women?

Yes No

Does your dog enjoy playing with toys?

Yes No

Does your dog enjoy treats?

Yes No

Has your dog ever injured a person?

Yes No

Notes / Reason for Surrender

Surrender Statement

I agree to relinquish ownership of this animal to the shelter.

I Agree

Signature

Sign here

Upload a Photo of Your ID as Proof of Residency

Max 10 MB per file

Dog Surrender Form

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