NORTHEASTERN BOXER RESCUE



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Adopt A Boxer Rescue

 PO BOX 270551 West Hartford, CT 06127

Phone: 877 570 0360   email: Surrender@

OWNER RELEASE AGREEMENT Pg 1 of 2 [161101]

DATE__________________SEX: M / F ALTERED: Y / N AKC#_____________ COLOR___________________________________

DOG'S REG. NAME_________________________________ CALL NAME______________________________ AGE____________

OWNER'S NAME_____________________________________________ PHONE_________________________________________

OWNER'S WORK PHONE_____________________________________ OWNER'S E-MAIL_________________________________

OWNER'S ADDRESS__________________________________________________________________________________________

BREEDER__________________________________________________________________________________________________

REASON FOR SURRENDER___________________________________________________________________________________

___________________________________________________________________________________________________________

MEDICAL INFORMATION

VETERINARIAN_____________________________________________________________PHONE__________________________

VACCINATION RECORD_______________________________________________________________________________________

DATE OF LAST DEWORMING______________________ DATE OF LAST HEARTWORM CHECK____________________________

CURRENTLY ON HEARTWORM PREVENTATIVE Y / N IF YES, DATE OF LAST PILL___________________________________

IF ON HEARTWORM PREVENTATIVE PLEASE NAME TYPE_________________________________________________________

AT WHAT AGE WAS DOG NEUTERED__________________ HAS DOG EVER BEEN BRED? Y / N HAD PUPPIES? Y / N

HAS DOG EVER BEEN TREATED FOR A MEDICAL PROBLEM? Y / N IF YES PLEASE EXPLAIN__________________________

___________________________________________________________________________________________________________

OTHER INFORMATION

HOUSETRAINED? Y / N CRATE TRAINED? Y / N LEASHTRAINED? Y / N BARKER? Y / N

DIGS? Y / N DOG AGGRESSIVE? Y / N JUMPS FENCE? Y / N OBEDIENCE TRAINED? Y / N

WHAT COMMANDS ARE KNOWN?______________________________________________________________________________

___________________________________________________________________________________________________________

OWNER RELEASE AGREEMENT Pg 2 of 2 [161101]

TYPE OF DOG FOOD_________________________________________________________________________________________

FEEDINGS PER DAY AM_____ PM_____ BOTH_____ QUANTITY FED______________________________________________

WHERE DOES DOG SLEEP? __________________________________________________________________________________

USED TO BEING ALLOWED ON FURNITURE? Y / N GIVEN FREE ACCESS TO HOUSE? Y / N

HOW MANY HOURS IS DOG USED TO BEING LEFT ALONE?____________ DESTRUCTIVE WHEN LEFT ALONE? Y / N

WHERE IS DOG LEFT WHEN NO ONE IS AT HOME?_______________________________________________________________

GOOD WITH CHILDREN? Y / N UNSURE___ IF YES, WHAT AGES?_________ FRIENDLY TOWARDS STRANGERS? Y / N

GETS ALONG WITH CATS? Y / N UNSURE____ GETS ALONG WITH OTHER DOGS? Y / N UNSURE____

RIDES WELL IN CAR? Y / N USED TO A FENCED YARD? Y / N HAS A TENDENCY TO RUN OFF? Y / N

HAS YOUR DOG EVER ATTACKED ANOTHER ANIMAL? Y / N IF YES, EXPLAIN CIRCUMSTANCES:_______________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

HAS YOUR DOG EVER BITTEN, OR ATTEMPTED TO BITE A PERSON? Y / N IF YES , EXPLAIN CIRCUMSTANCES__________

___________________________________________________________________________________________________________

HOW LONG HAVE YOU OWNED THIS DOG?______________________________________________________________________

WHERE DID YOU GET HIM / HER?______________________________________________________________________________

It is understood that ADOPT A BOXER RESCUE does not buy or pay for dogs. This is a service to help place Boxers in new homes when their present owners can no longer keep them. This service is free, however a donation to help pay for expenses is appreciated. Most of the dogs we handle come from Animal Shelters, and require considerable expenses prior to adoption. Everyone associated with ADOPT A BOXER RESCUE are volunteers.

PLEASE READ, SIGN, AND DATE THE FOLLOWING:

I, ________________________________________________, hereby make available for adoption the BOXER, named __________________________________________________, to ADOPT A BOXER RESCUE. I certify that I am the owner of this dog, free and clear of all other interests. I certify that this dog does not possess any dangerous or vicious propensities, and that I have not willfully concealed information about the dog that might indicate such propensities.

The information I have provided about this dog is true and complete. I hereby forever release, discharge and agree to hold harmless and indemnify ADOPT A BOXER RESCUE, its board of directors, its members, officers, and agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above named dog.

OWNER'S NAME (Please Print):_________________________________________________________________________________

I also agree my name and phone number may be released, only if needed, to the new owner of this dog. And that the new owner may contact the dog’s vet, or me, to gain further information on this dog.

SIGNED BY OWNER:________________________________________________________ DATE:________________________

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