Owner Surrender



Southeast Corgi RescueKavita Nanda, Rescue Coordinatormorgancorgi@Owner Surrender AgreementName of Owner(s):Date:Address:City:State:Zip:Email Address: Home Phone:Cell Phone: Name of dogSex:Date of birth/Age:Weight:Spay or Neutered:Color/Markings:What dog food is he/she on?Amount and frequency of feedings?WeightRegistered with AKC or other organization? Proof of ownership (receipt or contract, if available):If purchased from a breeder, Breeders name/address. Sometimes they will take their dogs back)Name of veterinarian:Phone:Address of veterinarian::Date of last vaccinations:Name of heartworm medication:Flea/tick prevention?When were heartworm meds last given? If dog has not been on HW medication, please have your vet do a HW testFlea/tick last given?Medical or behavioral problems PLEASE EMAIL ALL VET RECORDSHas your dog ever bitten a human; please explain circumstancesANY behavioral problems that we need to know about. E.g., thunderstorm anxiety, nervous around children or men, on medication for _____________________.If we ascertain that this dog has behavioral or medical problems that weren’t disclosed here, Southeast Corgi Rescue reserves the right to return to the dog to it’s owner. Temperament:Circle or check ALL that Apply:Does the dog like? Other dogs-has he been around other dogs? Cats Children Strangers Car Rides Walks on leash Does the dog NOT like Other dogs-has he been around other dogs? Cats Children Strangers Car Rides Walks on leash Where does the dog stay? Loose in house Crated Tied Dog house Loose in yard In yard at all timesPlease explain any of the above Habits: House trained Crate trained Obedience trained Marks territoryOTHER Runs away Howl/barks Possessive of toys Guards foodOther:Temperament: Friendly Enthusiastic Anxious to please Outgoing Reserved Protective Cautious Shy / Timid Stubborn Calm Lethargic Aggressive Dominant SubmissiveOther:PLEASE PROVIDE ADDITIONAL INFORMATION HEREOther comments regarding behavior:Reason for relinquishing: I understand that with this agreement the dog becomes the property of Southeast Corgi Rescue. I hereby release full ownership of my dog to Southeast Corgi Rescue. _____ InitialsI will make no attempt to reclaim my dog, but I understand that Southeast Corgi Rescue reserves the right to return to the dog to me if they ascertain that this dog has behavioral or medical problems that weren’t disclosed._____ InitialsI grant Southeast Corgi Rescue the right to give my dog any medical treatment deemed necessary and to place the dog in an approved foster and/or adoptive home._____ InitialsI release Southeast Corgi Rescue from all liability, legal or otherwise concerning said dog. Southeast Corgi Rescue will make every attempt to provide adequate foster care, but is not liable for any action of said animal or accident sustained. _____ InitialsI give permission to Southeast Corgi Rescue and its volunteers to contact my veterinarian regarding my dog. I give my veterinarian permission to provide copies of my dog’s health records. Please have your vet email all records to morgancorgi@By signing this agreement, I fully understand and accept the terms of this Owners Surrender Agreement. _______________________________________________Owner's Signature DatePlease send any items such as a collar leash, rabies tag, medicine, etc. If she has toys, or adog bed she loves, please send. In addition, please send a week’s worth of food that the dog is on so we can gradually change her over to food we will feed. TRANSPORT: We are an all-volunteer group and may ask that you help us in picking up your dog by driving a given distance. ................
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