Owner Surrender Questionnaire
Please answer the questions honestly and be as detailed as possible. This will help is in determining if we will be able to accept your dog in to our rescue.
Please note that shelter dogs in need will take precedence over any owner surrendered dog. Due to the lack of foster home, in most cases, you will be required to "foster" your dog until a home can be found.
This information MUST be submitted along with a photograph before we will consider accepting your dog in to our program.Upon completing the below information, IMMEDIATELY email the form and a picture of your dog to . No further action is required. As a 100% volunteer organization, we will contact you as soon as possible.
Owner Information
Name:
Street Address:
City/State/Zip:
Daytime Phone Number:
Evening Phone Number:
Mobile Phone Number:
Best time to contact you:
Email address:
Dog Information
AKC Name:
Call Name:
AKC Number:
Date of Birth:
How Originally Acquired Dog:
When Acquired:
If from a Breeder, have you contacted them?
If from a breeder, please provide their contact information.Why are you wanting to surrender your German Shepherd?
When does dog have to leave your home?
Are you willing to foster the dog after legally relinquishing the dog to us until a permanent home can be found?
Dog’s Physical Appearance
Sex:
Age:
Color:
Height: Weight:
Tattoo:
Micro Chip (Make & Number):
Scars, Broken Teeth, etc.:
General overall appearance:
Medical History
You must provide AGSR with copies of the dog’s entire medical history file PRIOR to the dog being accepted in to our care.
Veterinarian Name:
Address:
City, State, Zip:
Phone:
Date of Last Visit for this dog:
Vaccination History(Dates Last Received)
All Dogs MUST be current on all vaccines, be spayed/neutered and have a current heartworm test PRIOR to acceptance.
Does the dog have any current known medical issue that requires immediate attention? If yes, please explain.
Is the dog currently in good health? If not, please explain.
DHLPP:Rabies: Bordetella:
Date of HEARTWORM Test: Results:
Currently on Preventative:What Brand:
IS THIS DOG IS SPAYED/NEUTERED?
Allergies:
Medical Problems:
Medications Required:
Surgeries:
Ever Required Emergency Care:
Current Dog Food:
Current Feeding Schedule & Quantity:
Personality Traits (please check all that apply)
Likes
Dogs Cats Other Small Animals Children Strangers Visits to Vet: Running/Jogging
Crates Car Rides Toys/Play Water Being Groomed Traveling
What ages kids has the dog been around safely
Dislikes/Habits
Dog Aggression Food Aggression Toy Aggression Fence Jumping Escapes Yard
Digging Separation Anxiety Barking when left unattended Destructive Chewing
Scared of Thunderstorms
Other Fears/Dislikes:
Other Aggressions:
Temperament Towards Humans
Friendly Shy Cautious Outgoing Hyper EnergeticCalm
Anxious Dominant Submissive Submissive Peeing ObedientChallenging
Temperament Towards Other Dogs
Friendly Shy Cautious Outgoing Hyper Energetic
Calm Anxious Dominant
Submissive Obedient Challenging
Has dog ever bitten a human? If yes describe situation, location, when, seriousness of bite, etc.
Has dog ever nipped/shown aggression towards a human? If yes describe situation, location, when, etc.
Types of Training this dog has had:
house trained obedience trained rides in car
Is the dog crate trained:
Describe any behavioral problems you have experienced.
I would consider this dog to have a energy level.
Dog’s History and Experiences
House dog Outdoor Dog Tied Up Contained in Open Yard
Has this dog ever been:
Abused Neglected in any way Hit by a car Bred Allowed on Furniture
Allowed to run off-leash in a NON-fenced in area Attacked by another animal Used to wearing a collar
How does this dog signal to go outside:
What words or commands does this dog know:
Items You Are Sending with the Dog
Toys Crate/Bed Food Collar w/tags Leash Medication
Can you foster the dog until placed?
If unable to foster, can you sponsor boarding at rescue rates?
Can you sponsor the dog’s medical treatment?
How long can you keep the dog?
Please be advised we will want to speak with your veterinarian. Please contact your veterinarian to let him/her know we will be calling and that you authorize him/her and/or their representatives to release all records of your dog to us.
By submitting this form, I hereby swear that:
•The dog hereby discussed is owned by me.
•The above information is true and complete to the best of my knowledge and ability about the dog.
•I understand that the dog will be further evaluated by AGSR to determine whether or not it is adoptable.
•All information related to temperament (especially biting incidents) have been disclosed above.
Type in your name:
Today's Date:
If AGSDR has foster space available, we will contact you.
Please email this form to .