Dog Surrender Agreement and Background Information

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1 and Background Information Please take the time to fill out this form accurately, honestly, and with as much detail as possible. This information helps us match your dog with a potential adopter. Date: Dog s Name: Age: Breed: Description: Sex: Male / Female Altered: Yes / No At What Age: Date of Birth (If known): Current on Vaccinations: Yes / No Rabies Tag No: City of UC License Tag No: 1. Reason for surrender: 2. How long have you owned the dog? 3. Has the dog ever been kenneled? (Check all that apply): o Veterinarian o Boarding Facility o Never 4. Where did you get this dog? o Humane Society o UC Animal Care & Control (here) o Breeder o Pet Shop o Other Shelter o Found o Friend/Relative o Newspaper o Had since birth 5. What was the dog s approximate age when you got it?

2 6. How would you describe this dog s behavior around children? (Check all that apply) o Friendly / playful o Gentle o Afraid of o Snappy with o Never been with o Tolerant 7. List types, ages, sexes and sizes of other animals who lived with this dog: 8. Please describe the dog s behavior around other dogs. (Check all that apply) o Friendly / Playful o Rough Houses o Dominant o Frightened of o Ignores o Gentle and Submissive o Has never been around other dogs 9. Please describe the dog s behavior around cats. (Check all that apply) o Friendly / Playful o Frightened of o Ignores o Chases o Has never been around cats o Has killed 10. Is the dog housebroken: Yes / No If yes, how does the dog let you know when it needs to go out? 11. Is the dog crate trained? Yes / No

3 12. Is the dog destructive? Yes / No If yes, please describe. (Check all that apply) o Chews or scratches when alone o Chews or scratches furniture/rugs/etc. o Chews sticks / trees o Chews or scratches on windows/doors to get in o Chews or scratches on windows/doors to get out o Chews owners belongings o Digs randomly in yard o Digs at fence line 13. Where does the dog usually sleep at night? (Check all that apply) o Crate o In owners room o In owners bed o Garage o In child s room o In child s bed o Outside o Loose in house 14. Where is the dog kept when no one is home? (Check all that apply) o Crate o Loose in house o Garage o Fenced yard o Tied in backyard o Outside 15. Would you say the dog spends more time: o Indoors o Outdoors 16. Is your yard fenced? Yes / No 17. How high is your fence? o 4 ft o 6 ft 18. What is the fence made of (Check all that apply) o Chain link o Wooden/privacy

4 19. If your yard is not fenced, how is the dog confined to the property? 20. Does the dog stay confined in your yard? Yes / No If no, how does he escape? (Check all that apply) o Climbs fence o Jumps fence o Chews/Eats through o Digs out o Opens gate 21. What is the dog s favorite activity? (Check all that apply) o Fetch ball or Frisbee o Squeaky toys o Stuffed animals o Rope toys o Chew bones 22. What type of training has the dog had? o Obedience classes o Home training o None 23. What does the dog know how to do? o Sit o Stay o Come o Down o Walk on a leash 24. Does the dog like to ride in cars? Yes / No 25. Is the dog frightened of anything? (Check all that apply) o Men o Women o Children o Vehicles o Lightening/thunder o Water o Other dogs o People in uniforms

5 26. What do you normally feed the dog? o Dry food o Canned food o Dry and Canned mixed o Table scraps 27. How does the dog behave during grooming? (bathing, nail trimming, etc.) o Scared o Calm/Relaxed o Never been groomed 28. Has the dog ever: o Growled o Snapped o Bitten o Other displays of aggression: o None of the above 29. Do you feel the dog is protective or possessive? Yes / No If yes, explain: 30. Does the dog have any skin problems? Yes / No If yes explain: 31. Does the dog have any special medical needs? Yes / No If yes explain: 32. Does the dog have any special dietary needs? Yes / No If yes explain: 33. Did you bring in all vet records? Yes / No 34. Which vet have you used previously? 35. Has the dog been on any kind of heartworm prevention? Yes / No If yes, what type and when was it last given? 36. Has the dog been on any kind of flea and tick prevention? Yes / No If yes, what type and when was it last given?

6 37. Does the dog have: o Tatt00 o Microchip o None o Not sure 38. Has the dog ever bitten or scratched a person? Yes or No If yes, provide the following information. o Date of bite or scratch: o Did bite or scratch break the skin? Yes or No o Name of person bitten or scratched: o In what City did bite or scratch occur: o Was animal control involved? Yes or No If yes, provide details of bite or scratch? 39. I hereby certify that the above described dog has NOT bitten or scratched any person in the last ten (10) days. Initial Additional information you can provide about the dog: Thank you for taking the time to answer this questionnaire thoroughly and honestly. Owners Name: Drivers License No. Address: City State Zip Day Phone: Evening Phone: I hereby certify that the above information is correct, that I am the legal owner or custodian of the above described animal, and have the authority to surrender the animal to the Universal City Animal Care and Control (ACC) and hereby authorize release of any veterinary records regarding the animal and relinquish all rights of ownership and any right to information on the disposition of the animal.

7 I understand that the ACC cannot guarantee the adoption of any animal; the animal may be adopted, transferred or euthanized at any time due to illness, disposition or space restrictions. I further acknowledge that the animal will not be returned to me except under normal adoption conditions and agree to reimburse the ACC for its expense for caring for the animal and any expenses associated with preparing and holding the animal for adoption, I understand these fees may exceed the normal adoption fee. Signature Date Received by Date

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