Home Surrender Form – Dogs

Surrender Form – Dogs

"*" indicates required fields

Your Information

Full Name*

Address*

City/Town/RM*

Province*

Postal Code*

Phone Number*

Email Address*

Why are you surrendering your dog/puppy?*

Are you able to pay the surrender fee?*

Payable upon surrender

If other, put details here:

Donation amount, type of food/supplies

Dog Information

Dog's Name*

Dog's Age (approximately)*

Breed*

Size (small, medium, large, extra large)*

Colouring*

Approximate Weight*

Gender*

Male

Female

Unsure

Spayed/Neutered*

Yes

Unsure

Vaccinated*

Yes

Unsure

Tattooed/Microchipped*

Yes

Unsure

Where did you get the dog/puppy?*

How long have you had it?*

How many homes (including yours) has the dog had?*

Behaviour

How does the dog behave with adult men (choose all that apply)?*

Playful/Friendly

Protective/Aggressive

Barks/Growls

Snaps/Bites

Chases

Unknown

Please explain in more detail:

How does the dog behave with adult women (choose all that apply)?*

Playful/Friendly

Protective/Aggressive

Barks/Growls

Snaps/Bites

Chases

Unknown

Please describe in more detail:

How does the dog behave with children under 16 (choose all that apply)?*

Playful/Friendly

Protective/Aggressive

Barks/Growls

Snaps/Bites

Chases

Unknown

Please explain in more detail:

How does the dog behave with visitors and strangers (choose all that apply)?*

Playful/Friendly

Protective/Aggressive

Barks/Growls

Snaps/Bites

Chases

Unknown

Please explain in more detail:

How does the dog behave with cats (choose all that apply)?*

Playful/Friendly

Protective/Aggressive

Barks/Growls

Snaps/Bites

Chases

Unknown

Please explain in more detail:

How does the dog behave with other dogs (choose all that apply)?*

Playful/Friendly

Protective/Aggressive

Barks/Growls

Snaps/Bites

Chases

Unknown

Please explain in more detail:

Has the dog ever bitten a person?*

Yes

Please explain in more detail:

Has the dog ever been in a serious dog fight or injured another dog?*

Yes

Please explain in more detail:

Has the dog shown predatory behaviour?*

Yes

Unknown

Has the dog shown guarding behaviour towards food, toys, resources, or space?*

Yes

Unknown

Number of people living in the home with the dog?*

Include number of ALL adults and children

Number of children (age 16 or under) living in the home with the dog?*

Only AGES of children required

Did the dog get along with everyone living in the home?*

Yes

Please explain in more detail:

Has the dog shown any guarding behaviours over certain family members?*

Yes

Unknown

Please explain in more detail:

Is the dog house trained?:*

Fully housetrained (no accidents)

Rare accidents (less than 1 time per month)

A few accidents a month

A few accidents a week

Accidents every day

Does the dog display destructive behaviour?*

Yes

When (choose all that apply)?

A human is home

Left alone

During the day

At night

Please describe in more detail:

Is the dog kennel/crate trained?*

Yes

Unknown

How is the dog confined while in the home alone?*

Kennel/crate

In a room

Not confined

Where does the dog sleep at night?*

Indoors

Outdoors

Where does the dog spend most of its day?*

Indoors

Outdoors

Please describe in more detail:

How long is the dog left alone on an average day?*

How does the dog react when left alone?*

Has the dog lived with other pets in the past?*

Cat(s)

Dog(s)

Other (Explain below)

None

How many, and how did they get along?

Handling Tolerance (choose all that apply):*

Allows being pet

Allows being groomed (brushed/bathed)

Allows being played with

None of the above

Does the dog like to be picked up?*

Yes

Sometimes

Too large to be picked up

Unknown

What type of training have you used with the dog? Please describe the methods used:*

Please describe in more detail:

If let off-leash, what would the dog do? Please describe in detail:*

Does the dog understand basic commands (sit, stay, etc)?*

Yes

Can the dog perform any tricks?*

Yes

Unknown

Do you walk the dog?*

Yes

What type of collar/harness do you use?

Do you have any problems walking the dog?

Yes

Please describe in more detail:

How much and what kind of daily exercise does the dog receive?*

Does the dog like to play?*

Yes

Please describe how and with what the dog plays:

How would you describe the dog's personality?*

What do you like best about the dog?*

What are some of the dog's favourite things?*

How well does the dog handle traveling in a vehicle (short and long distances)?*

What is the dog afraid of and how does it react? Please describe in detail:*

Health

When was the last time the dog was seen by a veterinarian?*

How often does the dog visit the veterinarian?*

How does the dog behave during vet visits?

Does the dog have any allergies?*

Yes

Unknown

Please describe in more detail:

Is the dog on any medications?*

Yes

Please describe in more detail:

Has the dog had any health problems in the past?*

Yes

Unknown

Please describe in more detail:

Does the dog currently have any health problems?*

Yes

Please describe in more detail:

Additional Information

Is there any additional information you would like us to know about the dog?

Last modified: August 3, 2024

What the Floof?

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The Pembina Valley Humane Society is a volunteer-run, non-profit organization serving the communities within the Pembina Valley and beyond.

Charitable # 852072370RR001

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462 Jefferson Street
Morden, MB R6M 1Y4

The PVHS is located on the original lands of the Anishinaabeg, Cree, Oji-Cree, Dakota and Dene peoples, and on the homeland of the Métis Nation. We respect the Treaties that were made on these territories, we acknowledge the harms and mistakes of the past, and we dedicate ourselves to moving forward in partnership with Indigenous communities in a spirit of reconciliation and collaboration.

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