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Owner Release Agreement  - (Please print out and mail to address below)

Midwest Small Breed Rescue
P.O. Box 36035
Grosse Pointe, MI 48236

 

DATE__________________SEX: M / F  ALTERED: Y / N   AKC#_________________________ COLOR_______________________

DOG'S REG. NAME_________________________________  CALL NAME______________________________ AGE____________

OWNER'S NAME_____________________________________________  PHONE_________________________________________

OWNER'S WORK PHONE_____________________________________  OWNER'S E-MAIL_________________________________

OWNER'S ADDRESS__________________________________________________________________________________________

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BREEDER__________________________________________________________________________________________________

REASON FOR SURRENDER___________________________________________________________________________________

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MEDICAL INFORMATION

VETERINARIAN_____________________________________________________________PHONE__________________________

VACCINATION RECORD_______________________________________________________________________________________

DATE OF LAST DEWORMING______________________ DATE OF LAST HEARTWORM CHECK____________________________

CURRENTLY ON HEARTWORM PREVENTATIVE    Y / N    IF YES, DATE OF LAST PILL___________________________________

IF ON HEARTWORM PREVENTATIVE PLEASE NAME TYPE_________________________________________________________

AT WHAT AGE WAS DOG NEUTERED__________________      HAS DOG EVER BEEN BRED?  Y / N      HAD PUPPIES?   Y / N

HAS DOG EVER BEEN TREATED FOR A MEDICAL PROBLEM?   Y / N    IF YES PLEASE EXPLAIN__________________________

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OTHER INFORMATION

HOUSETRAINED?   Y / N          CRATE TRAINED?   Y / N          LEASHTRAINED?   Y / N          BARKER?   Y / N

DIGS?   Y / N          DOG AGGRESSIVE?   Y / N          JUMPS FENCE?   Y / N          OBEDIENCE TRAINED?   Y / N

WHAT COMMANDS ARE KNOWN?______________________________________________________________________________

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TYPE OF DOG FOOD_________________________________________________________________________________________

FEEDINGS PER DAY  AM_____ PM_____ BOTH_____     QUANTITY FED______________________________________________

WHERE DOES DOG SLEEP? __________________________________________________________________________________

USED TO BEING ALLOWED ON FURNITURE?   Y / N                     GIVEN FREE ACCESS TO HOUSE?    Y / N

HOW MANY HOURS IS DOG USED TO BEING LEFT ALONE?____________        DESTRUCTIVE WHEN LEFT ALONE?   Y / N

WHERE IS DOG LEFT WHEN NO ONE IS AT HOME?_______________________________________________________________

GOOD WITH CHILDREN?  Y / N   UNSURE___  IF YES, WHAT AGES?_________  FRIENDLY TOWARDS STRANGERS?   Y / N

GETS ALONG WITH CATS?  Y / N   UNSURE____                    GETS ALONG WITH OTHER DOGS?  Y / N  UNSURE____

RIDES WELL IN CAR?   Y / N                 USED TO A FENCED YARD?   Y / N               HAS A TENDENCY TO RUN OFF?   Y / N

HAS YOUR DOG EVER ATTACKED ANOTHER ANIMAL? Y / N   IF YES, EXPLAIN CIRCUMSTANCES:_______________________

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HAS YOUR DOG EVER BITTEN, OR ATTEMPTED TO BITE A PERSON?  Y / N    IF YES , EXPLAIN CIRCUMSTANCES__________

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HOW LONG HAVE YOU OWNED THIS DOG?______________________________________________________________________

WHERE DID YOU GET HIM / HER?______________________________________________________________________________

It is understood that Midwest Small Breed Rescue does not buy or pay for dogs. This is a service to help place dogs in new homes when their present owners can no longer keep them. A donation of $100 is required for basic medical and food expenses.

PLEASE READ, SIGN, AND DATE THE FOLLOWING: 

I, ________________________________________________, hereby make available for adoption of the dog, named __________________________________________________, to Midwest Small Breed Rescue. I certify that I am the owner of this dog, free and clear of all other interests. I certify that this dog is not possessed of any dangerous or vicious propensities, and that I have not willfully concealed information about the dog that might indicate such propensities.

The information I have provided about this dog is true and complete. I hereby forever release, discharge and agree to hold harmless and indemnify Midwest Small Breed Rescue, its board of directors, its members, officers, and agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above named dog.

OWNER'S NAME (Please Print):_________________________________________________________________________________

I also agree my name and phone number may be released to the new owner of this dog. And that the new owner may contact me if he wishes, to gain any further information on this dog. 

SIGNED BY OWNER:________________________________________________________  DATE:________________________