MIDWEST BOSTON TERRIER RESCUE
PO Box 297
Kent City MI 49330
MWBTR Owner SurrenderForm
Thank you for contacting Midwest Boston Terrier Rescue about the possible surrender of your dog. We received your request and have attached the Owner Surrender Form that will need to be completed and emailed back. If you have questions, concerns or problems, please contact the sender of this email.
The Surrender Form will help us find the best placement for your dog. Often times, problems that you are having with the dog can be corrected with training. We may be able to help you with training, based upon our knowledge and experience with the Boston breed or recommend a trainer in your area.
As soon as the Surrender Form is completed and returned we will review the information provided and advise you how to proceed. Should it be determined that placement with MWBTR is the only option we will contact you for placement of the dog in our foster program. Please note, that the information you provide to us is important, as this information will be used, along with a photo of the dog, to find the best possible home for adoption.
We focus more on quality than the quantity of adoptions, so our foster homes fill up fast. Your patience with us while working to bring your dog into foster care is appreciated as our foster homes often have more than one foster dog in their home.
Lastly, you may contact me at any time with questions or concerns. If I am not available to talk with you when you call, please leave a message and I will get back with you as soon as possible. As volunteers, we all have jobs and families, so it may take at least 24 hours before we are able to get back with you.
RELEASE AGREEMENT
I/we ______(hereinafter referred to a Owner[s]) attest that the dog,
______(hereinafter referred to as [the dog] described in the Surrender Profile legally belongs to me/us with no other party holding any lien or claim to the animal. I/we hereby give the dog to
______, a representative of Midwest Boston Terrier Rescue (hereinafter referred to as MWBTR).
I/we agree to relinquish all registration (including microchip) and medical records.
I/we agree to pass on all pertinent information regarding the dog, including history and temperament in the attached Dog Surrender Profile form.
Upon transfer of possession of the dog from Owner[s] to a MWBTR, Owner[s] relinquish[es] all interest, claims and rights, financial and otherwise. MWBTR will not be required to notify Owners[s] of the status or location of the dog at any time, including but not limited to the placement of the dog.
Upon transfer of the dog to a MWBTR representative, Owner[s] agree to hold MWBTR and all its representatives harmless regarding the dog.
In the event that you change your mind about relinquishing your dog to MWBTR, you and your family will be subject to he same conditions, fees and reference checks as any regular adopter. No exceptions.
Should a dispute arise over terms and enforcement of this contract, the parties agree to submit the matter to Arbitration before filing suit. The decision of Arbitration shall be binding on the parties and the cost of Arbitration shall fall on the party seeking to dissolve this agreement or its terms.
Owner[s] understand that MWBTR holds no element of confidentiality regarding this release form. It will be treated as public record, available to all person upon request.
Owner(s) agree to pay a surrender fee upon relinquishing the dog(s) in the amount of $______or equivalent supplies for the dog(s) (listed below):
______
______.
Surrender fee schedule (based on age and veterinary status (with documented proof from vet)):
- Dog is under 8 years of age:
- $25 - spayed/neutered and current on vaccinations and HW test/preventative
- $50 - spayed/neutered; not current on vaccinations and HW test/preventative
- $75 - not spayed/neutered; current on vaccinations and HW preventative
- $100 - not spayed/neutered and not current on vaccinations and HW preventative
- Dog is over 8 years of age:Additional donation suggested to cover senior veterinary care expenses.
This contract represents the complete agreement for surrender of the dog to MWBTR. All of the information provided in the Agreement and the attached Surrender Form, to the best of my/our knowledge is true and complete. By signing below, the parties agree to this contract.
Owner Name (print) & Signature:______Date: ______
Co-OwnerName (print) & Signature: ______Date: ______
MWBTR Representative (Name Signature): ______Date: ______
Rescue Tag Number Assigned: IN/IL/MI/OH # ______
DOG SURRENDER PROFILEName of Dog: ______/ Age: ____ / Sex:_____ / Birthdate: ______/ Spayed/ / ______
Neutered
Breed: ______/ Description:______
Where did you get him from originally? ______
How long have you had the dog? ______
Housebroken? ______/ Crate Trained? ______/ Food Brand? ______
Where does the dog sleep at night? ______
Health Problems? ______
Vet Clinic (Name, Address, and Phone Number)
______
______
______
Date of most recent:
Rabies: ______/ DHLPP: ______
Heartworm Test: ______/ Bordatella: ______
Heartworm preventative:______
HOUSEHOLD HISTORY
Individuals in the household: ______
______
Any Cats?______/ Dogs?______
Ages: ______/ Ages: ______
Does this dog ignore, play with, is bossy with, or grouchy with any of these other pets?
______
Do you have children in the household? ______
Ages: ______
Do any of them go to dog and play with dog?______
Outdoors or indoors? ______
Does dog tolerate them?______
Ignore them? Walk away if they get too close? ______
Does it seem the dog would like to play with them/be with kids forever? ______
Would he need to taught to be more gentle?______
Is he rough, or mouthy? ______
How often does he need a time out from the kids? ______
ACTIVITIES AND HOBBIES
What is dog's favorite kind of game to play? ______
______
Do you have a yard? ______/ Fenced? ______
Jumps Fence? ______
O.k. in a car? ______/ Does the dog like to swim? ______
Does the dog like to jog/run? ______/ Like being petted? ______
Like to play with kids? ______/ Like to play with dogs? ______
Like being brushed? ______/ Like obedience training? ______
Does dog go off leash? ______/ Does he stick around? ______
Will he come when you call him? ______
Does he fetch? ______/ A stick? ______/ A ball? ______
Does he entertain himself? ______
Does he get leash-walked? ______
Does he ever meet new dogs on his walks? ______
What is his reaction? ______
Do you let them sniff/touch/play? ______
Does you dog have a best friend/playmate? ______
Who? (describe breed type, age, and sex) ______
If a family is eating a meal, where is this dog at? ______
If you are in your living-room watching T.V., where is the dog? ______
HABITS WITH VISITORS AND HABITS ABOUT SELF
When guests/visitors/UPS or service-people come to the door,where is the dog kept?
______
If the dog is in house, is he free or does someone hold him by the collar or leash?
______
How long does it take him to calm down when someone comes to the house?
______
Has he ever nipped at anyone? ______
What parts of his body does this like to have touched or handled by visitors?
______
What parts of his body does this like to have touched or handled by family?
______
What has dog done to show you he/she doesn't like it?
______
Do you or have you ever petted or tired to go near your dog while he/she is eating or chewing on a
bone? ______
What is/has been the dog's response? ______
Is he/she better/worse with particular people/children in household? ______
______
Can you get garbage out the dog's mouth when he/she has stolen something out of trash or from
street? ______
Which of the following behavior problems does the dog display (check all that apply):
Jump on people _____ / Urinates/defecates in house _____ / Digs ______
Destructive chewing _____ / Chases cars/bikes ______/ Steals Food ______
Chases/kills livestock or cats ______/ Guards food/toys ______
Barks excessively ______/ Other ______
HELPFUL INFORMATION FOR THE NEXT OWNER
What is the dog's best qualities? ______
Who does the dog listen to/obey best in the household? ______
Why? ______
How is this dog best disciplined? ______
What kinds of naughty things does the dog do that you've needed to discipline for?
______
If you coud change one of their bad habits, what would it be? ______
What commands would be helpful to teach this dog before he goes to another home?
______
What are some of the cutest and nicest things about this dog? ______
______
What worries you most about placing this dog in a new home? ______
______
OWNER'S INFORMATION
Your Name:______
Signature: ______
Address: ______
______
Daytime Phone: ______
Nighttime Phone: ______
Email:______