First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Home Phone
Work Phone x
Cell Phone
Alt Email
Text/Pager Email
Name of Dog*
Breed*
Sex* Choose one: Male Female
Age (Date of Birth)
Does the dog have any scars or distinguishing marks? Choose one: Yes No
If yes, please list:
Is the dog spayed or neutered? Choose one: Yes No Dont know
Do you have AKC registration papers on this dog? Choose one: Yes No
Is the dog tattooed or micro-chipped? Choose one: Yes No Dont know
If yes, Registry & Number
Type or brand of dog food given and feeding directions:
Name of Veterinarian:
Phone
Please provide information on the following vaccinations (email copies of vet info if possible).
Rabies Choose one: Yes No Dont know
Date last given?
DHLPP Choose one: Yes No Dont know
Date last given
Bordatella Choose one: Yes No Dont know
Fecal Choose one: Yes No Dont know
Date last done
HW Test Choose all that apply: Yes No Dont know
Is the dog on any heartworm preventative Choose one: Yes No Dont know
If so, brand and date last given?
Is the dog on flea and tick control Choose one: Yes No Dont know
If so, brand and date last given
Has the dog ever sustained major injuries? Choose one: Yes No Dont know
If so, list:
Has the dog ever suffered any serious diseases? Choose one: Yes No Dont know
If yes, list
Does the dog currently have any condition that requires medical treatment or special care? Choose one: Yes No
If yes, please describe
Are you able to provide a complete medical record on this dog? Choose one: Yes No
Is the dog house trained?
Is the dog leash trained?
Is the dog crate trained?
Is the dog good with children?
Is the dog good with other dogs?
Is the dog good with cats?
If dog is NOT good with any other livestock or animal, please specify
Has the dog ever shown ANY signs of aggression (such as food, toy, gender, etc) ? Choose one:
If Yes, explain:
Has the dog had basic obedience training? Choose one: Yes No
Has the dog been known to climb? Choose one: Yes No
Has the dog been known to dig? Choose one: Yes No
Will you take the dog back if it does not work out in the foster home until an adoptive home can be found?* Choose one: Yes No
Please list any characteristics a new owner may want to know about the dog (Please elaborate as this is VERY HELPFUL):
Please explain why you are relinquishing the dog*
RELEASE OF OWNERSHIP AGREEMENT: I agree and understand that I am giving up all rights of possession and ownership of the described dog and that I will not be able to redeem this dog at any time. I agree and understand that this dog is now the "sole property" of “SHELTIE SHACK RESCUE OF KANSAS, INC. aka SSRK”. I promise that the information I am giving is accurate, and that SSRK will not be held liable or chargeable for any false information or misrepresentations that I may have submitted on this form. I further agree and understand that SSRK will do whatever is necessary for the safety and well-being of this dog. * Choose one: Yes No
Previous Owner Name*
Address*
City*
State*
Zip*
Home Phone*
Alternate Phone*
Drivers License*
Has the dog ever bitten anyone Choose one: Yes No Dont know
