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Name:
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Email Address:
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Relinquishment of Rights
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Please complete this form, providing as much
detail as possible. After you have completed the entire form, click on "SUBMIT" when ready to send. Please be careful not
to press "ENTER" before completing the form.
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(NOTE:
If you do accidentally press "ENTER," please resubmit your form. If you are given the option of continuing to fill out the
form, please do so and press "SUBMIT.")
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Your name
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Address
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Phone
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E-mail
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Pets name
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Pets breed
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This animal is
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Approximate weight
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Length of time you�ve owned this animal
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PREVIOUS OWNERS
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Name
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Address
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Formal obediance training? If yes when and where
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Walks nicely on a leash?
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Pulls sometime?
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Yes
No
Other
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Sits on command?
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Yes
No
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Lays down on command?
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Yes
No
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Comes always when called?
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Other training-related comments
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Never has a problem with other dogs?
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Sometimes has problems with male dogs?
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Sometimes has problems with female dogs?
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Has problems with dominant dogs?
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Is dominant, himself or herself?
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Is submissive, himself or herself?
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Is indifferent?
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Explain, if necessary
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Has lived with cats
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Has been around cats and is okay with them?
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Ignores cats?
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Chases cats because of interest?
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Chases cats as prey?
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Explain, if necessary
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Has your dog ever had formal obedience training? Please describe.
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Has your dog ever seen a behaviorist? Please describe.
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Is okay with children?
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Prefers older children?
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Has not been around children?
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Plays with (check all that apply)
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Completely housetrained?
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Sometimes has accidents?
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Needs to be housetrained?
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How does dog tell you he or she wants to go out?
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Is okay with a fenced-in yard?
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Yes
No
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Jumps fences?
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Yes
No
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Digs in yard?
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Yes
No
Sometimes
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Does the pet have any fears (i.e., thunderstorms, loud noises, etc.)?
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Does the pet chew things up?
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If yes, what?
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Can you take things from your pets mouth?
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Can you take toys and food away from your pet?
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Yes
No
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Is there any part of your pets body that it doesnt like touched (i.e., paws, tail, back, etc.)?
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Is your pet destructive when left alone?
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Has your pet ever bitten a human being?
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If yes, describe the circumstances.
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Has your pet ever killed another animal?
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If yes, describe the circumstances.
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Date last heartworm meds given
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Heartworm med type
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Date last flea treatment
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Rabies vaccination date
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Rabies period
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DHLPP vaccination dates
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Lyme disease vaccination dates
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Bordetella dates
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Date of last deworming
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Brand and type of food
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Fed
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How much exercise does the dog get daily?
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What sort of exercise? (For example, if walks, what distance? If yard time, how much?)
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Do you have another dog of other pets in the home? Describe.
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Where does the dog sleep?
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Names of medications your pet is on and dosages pet must take
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Has your dog ever been diagnosed with an ongoing medical condition such as epilepsy or hip dysplasia? If so, what?
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Provide any other information you believe would help the foster family for your pet
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Why are you giving up this pet?
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Are you willing to keep this pet until we can find a home for it?
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Applicants signature
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Date
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