RUFF MUTT BORDER COLLIE RESCUE
RELINQUISMENT APPLICATION
This form is used to evaluate the ability of Ruff Mutt Border Collie Rescue to accept the following dog into its rescue program. All information must be completed in order for the application for relinquishment to be reviewed. Failure to answer any of the following truthfully will result in the denial of the application and the refusal of the dog into rescue. If this dog is taken into rescue and it later comes to light that any information has been falsified, the owner will be held responsible for any resulting medical care or injuries that result.
OWNER INFORMATION
Name:
Address:
Home Phone:
Work Phone:
E-mail Address:
GENERAL INFORMATION
Dog's Name:
Gender:
Spayed/Neutered: Date of Alter:
Reason for surrender:
Age:
Date of Birth (if known):
Color and physical description of dog:
Coat type (rough, semi-rough, smooth):
Approximate weight:
Did you obtain this dog as a puppy? If so, where from? If not, where and when did you obtain this dog?
Is this dog a purebred border collie? If so, is it registered (list registry and registration number)? If not, what is it mixed with (if known)?
FEEDING
How many times a day is this dog fed?
What type of food does this dog regularly eat?
How much is this dog fed?
Any known allergies or types of food that the dog doesn't handle well?
Type of treats fed:
Favorite treats:
TRAINING
Does this dog respond to any hand signals?
Does this dog know basic commands of "sit", "down", and "stay"?
List any commands this dog knows and their meanings.
What command do you use for "NO"?
Has this dog been through any formal training? If so, list classes and when they were attended.
How is this dog disciplined or corrected for wrong behaviors?
Does this dog know any tricks?
Has this dog been trained in any type of canine sport/activity? (IE: frisbee, agility, herding, etc.)
ACTIVITIES
Does the dog enjoy exercise?
What type of exercise does the dog enjoy?
What type of toys does the dog play with?
Favorite toy:
Does the dog enjoy swimming?
DOES THE DOG LIKE (check all that apply):
Other dogs
Cats
Children
Walks
Riding in the Car
Strangers
Water
Play
Small Animals
Other:
HAS THE DOG BEEN (check all that apply):
Tied
Chained
Loose
Beaten
Housedog
Kenneled
Doghouse
Loose in Yard
Yard at all times
Yard part-time
Other:
HABITS (check all that apply):
Housebroken
Howls
Runs
Barking
Finicky eater
Signals to go out. What signal?
Used to collar and leash
Walks nicely on leash
Digs
Escape artist
Gets out to follow children
Jumps on people
Jumps fences
Chewing
Destructive
Vindictive
Gulps food
TEMPERAMENT (check all that apply):
Friendly
Enthusiastic
Outgoing
Cautious
Anxious to please
Happy-go-lucky
Aggressive
Shy
Protective
Very trainable/obedient
Hyper
Untrainable
Calm
Adaptable
Reserved
Stubborn
Lethargic
Inflexible
Is the dog "hand shy"?
Is the dog ever aggressive toward people or other animals? If yes, explain.
Please list anything the dog is afraid of:
Can you add anything to describe the dog's general temperament?
Has the dog ever bitten a person?
Explain:
Action taken:
MEDICAL HISTORY
Veterinarian:
Address:
Phone & Hours:
Rabies Vaccination: Date: Expires:
Other shots and dates:
Allergies:
Medications (Type and Dosage):
Deworming: Date:
Has this dog been heartworm tested in the last year? If so, list the result.
Is this dog on heartworm prevention?
If so, what brand and dose?
If female and not spayed, date of last heat:
Has the dog ever been bred? If so, when?
Has the dog ever had puppies? If so, when?
Any problems with eye sight?
Any problems with hearing?
Has the dog ever been injured?
Has the dog ever had a serious illness?
Does the dog have any chronic medical conditions?
OTHER
If RMBCR cannot take your dog into foster care at this time, what will happen to the dog?
I would be willing to keep my dog until a home is found:
I understand that there are certain conditions that must be met for any owner-surrendered dog to RMBCR.
Signed: