Returned Dog Form - Southern California Labrador Retriever

6XUUHQGHUQuestionnaire
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Name of dog:
How long have you owned this dog?
Age (or estimate):
Is the dog a mix?
If so, what do you think/know the breed mix to be?
Sex:
Weight:
Color:
Any special markings?
Spayed/neutered?
Date and type of last vaccinations?
Microchipped? Microchip # _________________________________________
Where did you acquire this dog from?
x If from a shelter, what is the name of the shelter?
x If from a breeder, what is the breeder's name & address (if known):
Do you have the registration papers on the dog (e.g. AKC)?
We always recommend you contact the breeder first – have you done this?
If yes, what was the breeder response?
Have you tried placing the dog yourself?
If yes, what have you tried and what problems have you encountered?
What brand food does dog eat?
How much does dog eat daily?
How many feedings/day?
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Southern California Labrador Retriever Rescue, Inc
24325 Crenshaw Blvd #137, Torrance, CA 90505
http://www.sclrr.org; [email protected]; 888-554-ALAB;
Rev. March 2013
1
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List veterinarian (name, phone):
Are shots up to date?
Will you provide copy of health records to SCLRR?
Does dog have any physical problems?
If yes, describe briefly:
Allergies?
If yes, describe:
On medication?
If yes, describe:
Has this dog had puppies before or been a stud dog?
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Has dog had obedience classes?
If yes, what school/trainer?
Any other training?
Housetrained?
Crate trained?
List commands, tricks, skills:
Who in family does dog obey?
Has this dog been socialized to dogs and places (example – has the dog gone camping, to the
beach, dog parks, etc.)?
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Dog typically spends days (choose one) Indoors
Outdoors
Southern California Labrador Retriever Rescue, Inc
24325 Crenshaw Blvd #137, Torrance, CA 90505
http://www.sclrr.org; [email protected]; 888-554-ALAB;
Rev. March 2013
Indoor/Outdoor
2
Dog typically spends nights (choose one) Indoors
Outdoors
Indoor/Outdoor
How much time does your dog spend typically in a crate or kennel (excluding night-time
hours)?
Is your dog ever tethered to a rope or chain for any length of time?
How does your dog react to:
Other dogs?
Cats?
Horses?
Strangers?
Children?
Walking on leash?
Meeting other dogs on leash?
Being alone in yard?
Being alone in house?
Being alone in car?
Surprises?
Loud noises (fireworks, thunder, etc.)?
Has this dog lived around children on a regular basis?
Does the dog:
Bark excessively?
Dig?
Chew?
Jump fences?
Roam?
Show shyness or fearfulness?
Have separation anxiety?
Show any territorial issues?
Fight with or show assertiveness with other dogs?
Snap or nip at people?
Growl when you take away food/toys or shows overly possessive tendencies?
Show fear of children?
Show fear of men?
Show fear of women?
Show fear of other dogs?
Has dog injured/killed other animals?
Southern California Labrador Retriever Rescue, Inc
24325 Crenshaw Blvd #137, Torrance, CA 90505
http://www.sclrr.org; [email protected]; 888-554-ALAB;
Rev. March 2013
3
If yes, describe
Has dog ever bitten a person?
If yes, describe
Did wound require medical attention?
Was bite reported to animal control?
Was dog quarantined?
What caused this bite?
Personality of Dog
What does dog like best?
Dislike or fear most?
Why is the dog being re-homed?
What is the most appealing thing about this dog?
Does this dog like water?
What is the dog's biggest fault?
Please write a synopsis of your relationship with this dog and why it hasn’t worked out,
including any changes in your life that have affected your decision to keep this dog.
I understand that all dogs placed by SCLRR must be up to date on their vaccinations
and that I will be asked to make a donation of $50 if vaccines are needed.
I understand that all dogs placed by SCLRR have to be spayed/neutered and that I will be
asked to make a $100 donation to cover this expense.
I understand that SCLRR may not be able to place this dog due to age, health, physical
condition, temperament, or lack of sociability.
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 propensities and that I have
not willfully concealed information about this dog that might indicate such propensities.
Southern California Labrador Retriever Rescue, Inc
24325 Crenshaw Blvd #137, Torrance, CA 90505
http://www.sclrr.org; [email protected]; 888-554-ALAB;
Rev. March 2013
4
I certify that the information provided on this form is true and correct, and I understand that
should SCLRR find any information contained in this surrender questionnaire to be false,
SCLRR has the right to turn down acceptance of the dog I am surrendering.
I understand that a physical evaluation of the dog and a temperament test will be performed by
an experienced SCLRR volunteer, and that decision whether SCLRR accepts this dog for re-homing
will depend, in part, on the results of such evaluation and testing.
I understand that once I have given up the dog in question, I am in no way to have him/her
back without the expressed agreement of SCLRR’s Board of Directors.
I understand that SCLRR reserves the right to refuse acceptance of any dog and that acceptance is
based on many criteria, one of which is space availability.
I have read and agreed with all of the above:
I have read and agreed with all of the above:
______________________________________________
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Southern California Labrador Retriever Rescue, Inc
24325 Crenshaw Blvd #137, Torrance, CA 90505
http://www.sclrr.org; [email protected]; 888-554-ALAB;
Southern C Rev. March 2013
;
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