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Surrender Agreement - Date: Great Dane Rescue of Minnesota and W. Wi PO Box 007 Albertville, MN 55301 gdromn@gmail.com http://www.gdromn.org Animal Information Name: Animal ID: Color: Color Pattern: Type: Breed: Sex: Age Group: Approx DOB: Age: Currently S/N?: Previously S/N?:
Dog ID:________________
Name of Owner:____________________________________
Home phone no.:____________ Cell phone no.:____________ Other phone no.:___________
Address: ________________________________City:_ ____________State:_ Zip Code_______
DOG INFORMATION
Dog’s Name: __________Color:_____________? Male ? Female ? Neutered ? Spayed
Date of Birth:__________________if unknown approximate age:_______________
Microchipped:____________Microchip Number/Manufacturer: ______________________
Registered: ________Registry/Number:________________________________________
Explanation of Tattoo: _____________________________________________________
Length of Time Owned: _____
Where Obtained:_________________________________
Name of Shelter/Breeder:__________________________
Gift Other:_____________________________________
Reason for Surrender: Please list all. __Moving __Finances __Animals health ___Owners Health
___Death of Owner ___Dogs Temperament __Other ____________________________________
Current Veterinarian/Clinic: __________________________________________
Veterinarian/Clinic Phone Number:____________________________________
Please notify your veterinary clinic of the surrender to GDROM and give permission for GDROM to access veterinary records for this dog.
Health Problems (List All):__________________________________________________________
Does the dog have: __Cardiomyopathy __Hip Dysplasia___HOD___Wobblers
___Heartworm___Lyme Disease__Curciate Ligament___Tapeworms___Ticks
___Fleas ___Hot Spots___Ear Infections ___Allergies__Thyroid problems
List Any Current Medications by name, reason for giving, dose and dates last administered to the dog
_______________________________________________________________________________
_______________________________________________________________________________
BEHAVIORAL INFORMATION
Is the Dog House Trained:____If yes How does the dog let you know he/she needs to go outside?
___________________________
Has the Dog Had Obedience Training:___If Yes What Type of Training:______________________
Does the dog walk nicely on a leash? ___ If NO Explanation of behavior:______________________
How does your dog react if you try to lead him by his collar?______________________________
Does your dog get along with male dogs? ___If No Explain behavior:_______________________
Does your dog get along with female dogs? ___If No Explain behavior:______________________
Has your dog been around cats? ___ If Yes Explain reaction towards cats:____________________
When does the dog bark?__________________ Is the barking excessive?____________________
Has the dog ever shown aggression towards another animal? ___(Aggression includes growling, snarling, lip curling, biting) If Yes Explain behavior:_____________________________________
Has the dog ever shown aggression towards a human? ___If Yes Explain behavior:_____________
_____________________________________________________________________________
Has the dog ever bitten/attempted to bite anyone? ___ If Yes Explain Each Incident in Detail:_____
______________________________________________________________________________
Does your dog guard their food/toys from other dogs/people? ___If Yes Explain behavior:_______
_____________________________________________________________________________
Can you easily take toys, food, rawhides, bones out of your dogs mouth? _____
Explain the dog’s behavior when riding in a vehicle:____________________________________
Is your dog used to being crated? _____
Is your dog playful? ___If Yes What are their favorite toys/games?_________________________
How much and what kind of exercise does your dog need each day?_________________________
Has your dog ever been swimming? ___If Yes Explain reaction to water:________________________
Does your dog runaway? ___If Yes How do you get it home?.______________________________
Does your dog chase cars?___ Does your dog enjoy being groomed? ____Explain reaction to grooming:____________________________________________________________________
Explain dogs reaction to toenails being clipped or ground:_______________________________
Does your dog like children? ___If Yes What ages?_______________________________________
Is your dog used to containment?___________ Check all that apply:___ Fenced yard ___ Invisible fenced yard ___ Outside dog run ___Tether Other:____________________________________
Does your dog jump/climb fences? ___If yes, how high?
Does your dog dig? ___
What scares your dog? (e.g. storms, separation, other dogs, men)___________________________
What is your dog’s reaction when scared?______________________________________________
When your dog is naughty, what is he/she doing?________________________________________
Additional relevant information:______________________________________________________
_______________________________________________________________________________
I certify that I am the legal owner of the dog described above and warrant and represent that this dog has never shown signs of aggression towards human beings and further warrant and represent that this dog has not bitten me or any other individual while in my possession. I hereby voluntarily relinquish all claims and ownership of said dog to the organization known as Great Dane Rescue of Minnesota and W. Wisconsin. ("GDROMN"). I am irrevocably transferring and relinquishing to GDROMN legal ownership of, and micro chip registration/re registration rights to this dog on the date hereof. I further acknowledge understanding that the dog becomes the property of GDROMN, and that GDROMN will spay/neuter this dog if intact, and will make every effort to place this dog in a new family setting. However, if the dog has serious health issues, serious behavior issues or aggressive issues, GDROMN has the right to euthanize the dog at its discretion.
By signing or electronically submitting this form, I hereby certify that I have honestly answered all of the above questions, to the best of my knowledge, and have read and completely understand the above release.
Signature of Owner:______________________________ Date:_____________________
Great Dane Rescue of Minnesota and W. Wi is a volunteer group. We request a donation to cover the cost of veterinary expenses, shots, spay or neuter, kennels, food, transportation, etc. Any amount you can give would be greatly appreciated. We also appreciate of jumbo crates, bedding, stainless steel bowls, the dog’s toys and any other items you would care to donate.
Donation Amount: $__________________You may also donate by going to www.gdromn.org <http://www.gdromn.org> and clicking on the PayPal Link or mailing a check to the address at the top of this form.
Signature of GDROMN Representative to acknowledge receipt of donation:________________________
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