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Your Information
Full Name:
Address Line 1:
Address Line 2:
City:
State:
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California
Canada
Colorado
Connecticut
Delaware
District of Columbia
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Indiana
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Maryland
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Missioui
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Home phone:
Work phone:
E-mail:
Dog's Information
Dog's name:
Dog's age:
Dog's sex:
Male
Female
Dog’s date of birth (if known):
Breeder’s name (if known):
Reason for relinquish:
Other comments:
Dog's Habits
Does the dog:
Like
Dislike
Other dogs
Children
Riding in the car
Water
Cats
Playing ball
Walks
Strangers
Has the dog been:
Yes
No
Tied up outside:
Loose outside:
Primarily a house dog?
Primarily an outside dog?
In a doghouse?
Chained?
Beaten?
Loose in the yard:
Kenneled:
In the Garage:
In the Basement:
Yard part time:
Habits (please check all that apply):
Housebroken:
Pulls on leash:
Jumps fences:
Chewing:
Gulps Food:
Digging:
Knows tricks:
Vindictive:
Barking:
Runs:
Finicky eater:
Escape artist:
Used to collar and leash:
Howling:
Gets out to follow children:
Destructive:
Walks nicely on a leash:
Jumps on people:
Dog's Temperament
Temperament (please check all that apply):
Friendly:
Shy:
Very trainable:
Anxious to please:
Obedient:
Un-Trainable:
Enthusiastic:
Stubborn:
Happy-go-lucky:
Suspicious:
Hyper:
Protective:
Reserved:
Calm:
Outgoing:
Lethargic:
Cautious:
Timid:
Adaptable:
Inflexible:
Can you add anything to describe the dog’s general temperament?
Has the dog ever bitten a person or another animal?
Select
Yes
No
Unknown
If yes, who were they and what were the reasons why he/she bit them?
Has the dog ever killed another animal?
Select
Yes
No
Unknown
If yes, when and why?
Dog's Appearance
Physical Appearance:
Select
White
Brown
Black
Red
Other
By using the Ctrl Key you can select multiple Answers.
Select
Small
Medium
Large
Eyes:
Select
Black
Brown
Blue
White
Other
Blind
Blind_one_Eye
Other:
Dog's Medical History
Medical History:
Veterinarian:
Address:
Phone #:
Vaccine Due Dates:
DA2PL/CPV/CCV
Heartworm Test:
Pos/Neg:
Select
Negative
positive
High Antigen
Low Antigen
Type of HWP
Rabies:
Bordetella:
Other Medical History (Illness, Allergies, Injuries, Physical Problems):
Food and Medication:
Number of feedings per day:
Select
1
2
3
Other
Amount fed at each feeding:
Cups
Type of medication and dosage:
There is a grace period of 3 (three) days should the owners/releasers change their mind and wish to reclaim the above-mentioned dog. If the dog is reclaimed, there will be a boarding fee of no less than $15.00 per day, plus any veterinary expenses and any additional expenses incurred during the course of the dogs stay with Saint Bernard Rescue. If you wish to waive you rights to the 3 (three) day grace period, please sign directly below. By signing below, it is hereafter understood that all rights of ownership to said dog are relinquished to Saint Bernard Rescue. Attorney Fees and Costs:
Should it become necessary for Saint Bernard Rescue to take legal action to defend itself or otherwise enforce the provisions of this Agreement, the Releaser(s) agree(s) to pay all court costs and reasonable attorney fees. All of the information I have provided in this form is, to the best of my knowledge, true and complete. I understand that falsifying answers in this form, or at any other time during the release process, disqualifies me from rescue taking my dog.
