Test OS – Carolina Boxer Rescue

Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name of Dog *

Dog's Age *

Birthdate (if known)

Dog's Gender *

Approximate Weight in Pounds *

Where was the dog obtained? *

Explanation of Where Dog was Obtained (if applicable)

How long have you owned the dog? *

Why do you want to surrender your dog? (Be specific) *

Veterinarian Name: (Enter N/A if unknown) *

Veterinarian Phone Number: (Enter N/A if unknown) *

Owner's Name Vet Records are listed under *

Is the dog current on vaccinations (Proof Required) *

Has the dog been spayed or neutered? *

Is the dog current on Heartworm preventative? *

If yes to heartworm preventative, what brand is the last pill/application?

Does your dog have any ongoing or previous medical issues? For example: allergies, ear infections, skin infections, etc. Please be as truthful and objective as possible. CBR takes in many dogs with medical issues. It is important that we know as much information as possible in order to place your dog in a foster home that is best suited to meet his/her needs. *

If you responded yes to medical issues, please describe medical issue(s) below along with any medications your dog is currently taking. Again, please be as truthful and objective as possible.

Please Attach Any Vet Records for Your Dog

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Is the dog microchipped? *

If the dog is microchipped, please enter the number

Is the dog housetrained? *

Explain housetraining issues

Is the dog crate trained? *

Is the dog mainly an indoor or outdoor pet? *

How does your dog do on a leash?

What kind of food/brand is the dog being fed? *

How often is the dog fed? *

How much at a time? *

Where does the dog sleep? *

Is the dog allowed on furniture? *

Does the dog have any known fears (thunder, fireworks, lawnmowers, etc.)?: *

Select adjectives that describe your dog *

Describe any training the dog has had: *

How does the dog react to common tasks such as bathing, nail trims, or ear cleaning? *

How does the dog react to being left alone? *

Is the dog destructive when left alone? *

What does the dog like? *

What does the dog dislike? *

Does your dog dislike - Please check all that apply. Please check all items that your dog has been exposed to and doesn't like. *

Does your dog like - Please check all that apply. Please check all items that your dog has been exposed to and likes. *

Does the dog jump fences? *

Is the dog a digger? *

Has the dog EVER bitten a human or animal?: Please be as truthful and objective as possible. It is important that we know as much information as possible to determine his needs. *

What was the worst level of bite?

Does the dog show signs of food aggression (For example: dog growls or snaps when someone/something comes near him/her when eating)? *

Does the dog show signs of resource guarding (For example: dog growls or snaps when someone/something comes near him when he has a toy, sitting on owner's lap, etc.)? *

Does the dog have any destructive habits to self or other objects? *

Does your dog have any other behavioral issues not previously discussed in this questionnaire? For example: anxiety, separation anxiety, depression, etc. *

Tell us how long your dog is used to riding in a car. We need this information because your dog may have to be transported to a foster home several hours away from where you live. Please pick the best choice that describes how long your dog is used to riding in a car. *

How does your dog do riding in a car? *

How does your dog usually travel in a car? *

Is there anything else you can think of that is special, unusual or endearing about your dog that would help the new owner? *

Photo/Video Consent: I grant Carolina Boxer Rescue permission to use any photos/videos provided for the purpose of listing and promoting the dog for adoption. *

Financial Contribution: I plan to make a tax-deductible donation to assist with the dog's care. (Optional)

an the I

Please include recent, well-lit images of your dog. *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Veterinarian Records Release I grant my permission for the above veterinarian to release all medical records pertaining to this dog to Carolina Boxer Rescue, Inc. and hereby give him/her my permission to discuss all medical diagnoses and treatments while said dog was in my care. Owner Surrender and Liability Release By signing my name, I certify that I am the person identified in this application and that this will be considered my electronic signature. I certify that I am the rightful owner of the above-named dog, and that there is no other person who has right of property in such dog, or (ii) I certify that I am a rightful co-owner of the above-named dog and that I am authorized on behalf of all the co-owners to release such dog, surrender all property rights in such dog, and transfer ownership of such dog, to Carolina Boxer Rescue. If the dog was found as a stray, I am the party that found them, and I took ownership at the end of the dog’s stray hold, in compliance of any city, county, or state laws. I hereby voluntarily relinquish all claims and ownership of said dog to Carolina Boxer Rescue, Inc. I understand I cannot reclaim this dog once the dog is in the possession of the rescue. I certify that all information provided herein is true and correct and that Carolina Boxer Rescue, Inc. or its agent will not be held liable or chargeable for any false information or misrepresentations. I certify that the above-named dog is not possessed of any dangerous or vicious behaviors and that I have not failed to disclose any information about the dog that might indicate such behaviors. I hereby release, discharge and agree to hold harmless and indemnify Carolina Boxer Rescue, its board of directors, officers, members, agents, representative and volunteers from all claims, demands, actions, cause of action or liability of any kind whatsoever arising as a result of or in connection with the adoption or any other disposition of the above-named dog.

Electronic Signature (Type Full Name)

Today's Date