RMCR Relinquishment Form


	Your Information

*First Name:

Middle Initial:

*Last Name:

*Street Address:

*City:

*State:

*Zip Code:

*E-Mail address:

*Home Phone Number:

- -	If you only have a cell phone, please place that number in this field.

Work Phone Number:

- - x

Cell Phone Number:

- -


	General Information About The Dog

*Dog's Name:

*Weight (pounds):

*Breed:

*Gender:

Male

Female

*Is the dog spayed/neutered?:

Yes	No
Unknown

*Age/Birthday:

*Description of dog:

*Why are you giving up this dog?:

(chars left: 2000)

Please be honest. The more information we have, the better chance we have of finding a good home for this pet and the sooner our foster parents can start to correct behaviors.


	Medical Information

*Veterinarian Name:

*Veterinarian's Phone Number:

- - x

*When is the rabies vaccination due?:

*When are other vaccinations due?:

*Does the dog have any new or old injuries or
health problems?:

Yes

No

If yes, please describe any injuries or
health problems:

*Does the dog need any medications or special
diet?:

Yes

No

If yes, please describe any medications or
special diet needs:

*When is the dog usually fed?:

AM

PM

Both AM and PM

Other:

*What brand of dog food is the dog being fed?:

*Will you provide copies of the medical
history from the vet?:

Yes

No


	Dog's Living Environment

*Have you had this dog its entire life?:

Yes

No

If you answered "No" to the last quesiton,
how long have you had this dog?:

*Did this dog ever live with other dogs or
other pets?:

Yes

No

If so, how did it work out?:

*Where and from whom did you acquire this dog?:

*How much of the time is this dog kept
outside?:

*How much of the time is this dog kept inside?:

*Where do you leave this dog when no one is
home?:

*How many hours a day (on average) does the
dog spend unsupervised?:

*Where does this dog sleep at night?:

Options:

Where does this dog sleep at night?:

Other:

*Is the dog a fence-jumper?:

Yes

No

If you answered "Yes" to the previous
question, how high is your fence?:

What is the fence made of?:

*Has the dog repeatedly escaped from your
yard?:

Yes

No

If you answered "Yes" to the previous
question, please explain how the dog escaped?:

When does the dog escape?:

All the time

When left alone

Other:

How long is the dog typically gone when
he/she escapes?:


	Training

*What type(s) of training has this dog had?:

Obedience training	Professional training
Home training	None

Comments regarding training:

*Does this dog know and respond to his/her
name?:

Yes

No

*Which commands does this dog understand?:

Other commands:

Which commands does this dog understand?:

Other:

*Does this dog know any tricks?:

Yes

No

If you answered "Yes" to the previous
questions, please describe the tricks this
dog knows.:

*Is this dog house trained?:

Yes

No

Comments regarding house training:

If your answer was "No", has this dog been
examined to rule out any physical problems
that might interfere with house training?:

Yes

No

*How often does the dog have accidents in the
house:

Once a day
Once a week
Every time the dog is in the house
When frightened
Rarely
Never

Comments regarding accidents:

*Is this dog crate trained?:

Yes

No

*How does this dog behave while in the crate?:

*Is this dog leash trained?:

Yes

No

*When leashed, does this dog exhibit any of
these behaviors (check all that apply):

Lunge at other dogs

Bark at other dogs

Lunge at people

Pull excessively

Other:

Leash behavior comments (is this behavior
aggressive or playful?):


	Behavior

*Has this dog ever bitten, snapped, or growled
at anyone?:

Yes

No

If you answered "Yes" to the previous
question, please describe the situation:

*Does this dog have any bad habits?:

Yes

No

If you answered "Yes" to the previous
question, please describe the dog's bad
habits:

What have you done to correct the habit
described above?:

*Is this dog a barker?:

Yes

No

*When does the dog bark?:

*Which of these triggers is the dog afraid of?:

Triggers:

Which of these triggers is the dog afraid of?:

Other:

What does he/she do when frightened?:

*Triggers:

Is the dog aggressive towards any of these?:

Triggers:

Other:

*Animals:

Please list which of these animals this dog gets along with or can be around:

Animals:

Other:

*Is this dog good with small children?:

Yes

No

If this dog is not good around small
children, please describe how the dog behaves
around them:

*Does this dog have any favorite toys or
activities?:

Yes

No

Please describe the dog's favorite toys or
activities:


	Animal Release Form

By clicking the Submit button on the bottom of this form, I agree that I am electronically transferring all of the data contained within this form and am certifying that (a) I am the guardian (also known as the "owner") of the animal described below and can provide proof of ownership; or (b) I am the authorized representative of the guardian or owner of the animal described below and can provide proof of such authority, such as Power of Attorney, or (c) I found the dog abandoned and have actively sought the rightful owners for at least seven (7) days and failed to locate them. I also certify that I have unrestricted and complete authority to surrender the animal to the Rocky Mountain Cocker Rescue. I understand that once I surrender this dog to Rocky Mountain Cocker Rescue, I relinquish all ownership rights and claims to that dog and that my ownership rights are terminated. I agree that by clicking on Submit, I am electronically signing this form and a physical signature is not required to proceed with surrendering this dog to Rocky Mountain Cocker Rescue.

*The name of the dog being surrendered is:

In addition, I agree that I may be asked to sign a hard copy of this form when the animal is surrendered.