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Owner Relinquish Form
Owners Name:___________________________________Address________________________________________
City/State______________________________________
Phone(s)____________________________________
Date:_______________ Dogs Name_______________________ DOB: ________________
Color:_______________ Sex______ Altered: ____________ Date of Alter:_____________ Dogs Age
Now:______________
- Does the dog like: Other dogs? ________, Cats? _______, Children?
_________Walks ?_______Riding in the car?__________, Car sick? __________ Strangers?
___________, Water (i.e.…lakes,ponds)? _____________Playing? _____________, Other?
___________________________________
- Comments:
_____________________________________________________________________________________
- Has the Dog ever been: House dog? _________ Kenneled?________,
Doghouse?__________Tied? _________, Chained? __________,
- Allowed to run loose?______________ In fenced yard?_____________, What % of day?
_________________, Abused by a person?________________Neglected? _________, Attacked by
other animal? ________, Hit by car?___________Allowed to breed? _______________,Comments:
_____________________________________________________________________________
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- The Dogs Temperament: Friendly?_______, Cautious? ______, Anxious to
please?_________Aggressive? _______, Shy?______, Afraid of People?____________Reserved?
________ Scared? _______ Confident? ______ Outgoing?_________Loves everyone?___________
Protective?_________, Obedient?__________, Hyper?___________Calm?______,
Trainable?_________, Stays nearby if loose? _____________ Will run away if loose?
____________________, Loves other dogs? ___________Dominant? __________________
Submissive? _______________ Good with children?___________Used to being around small
children?___________, Used to being around other dogs? _________ Used to being around
cats? _____________, ANY Dislikes: _______________________________________
Has this Dog ever bitten a person? __________________________________________________________________________
If yes, please give date and details______________________________________________________________________
Action Taken: ________________________________________________________________
Habits: Housebroken?________ Always____ Sometimes_____ Not at all_________
Explain: _____________Will signal if needs out? ___________ How?
___________________________________________________ Howls? _______ Cries at night?
________ Barks? ________________Finicky eater?__________ Walks on lead? __________ Used to
wearing a collar? _________Digs?__________ Escape artist?___________Jumps fences?
_____________ Will walk off with anyone? ____________ Chews? ___________
Destructive?______________________________Any other bad habits?
____________________________Tricks?________________ Words dog
knows?__________________________________Titles or Awards:
_______________________________________
Medical History: Last Vet Visit:
____________________________________Veterinarian Name_______________________________ Phone
____________________City/State________________________________________________________________________
Heartworm Test Given:_________ Date:______________ Heartworm Preventative Given?
_______Allergic to Anything?__________________Needs to be On ANY Medication:
_________________Are you delivering medication along with the dog?
________________________________
Items you are sending with Dog: Toys______ Food______ Collar _____ Leash
______Crate ______ Vet Records_______ AKC papers __________ Donation $______________________
It is understood that West
Virginia Sheltie Rescue does not buy or pay for dogs. This is a
service to help place Shelties in new homes when their present owners can no longer keep
them. This service is free, however a donation to help pay for expenses is appreciated.
Please read, sign and date the following:
I,_____________________________ , hereby transfer complete ownership of the Sheltie, named
_______________________, to
West Virginia Sheltie Rescue. I am giving this dog to West Virginia Sheltie Rescue knowing that they will place this dog in an adoptive home. I certify that I am
the sole, rightful owner of this dog, free and clear of all other interests. I certify
that all the information I have given above, is true and complete, and I have not
willfully concealed any information about this dog. I hereby forever release, discharge
and agree to hold harmless and indemnify West Virginia Sheltie 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.
I agree / do not agree to allow my name and phone number to be given to the new owner
of this dog, so that the new owner may contact me if he wishes, to gain any further
information on this dog.
SIGNATURE OF OWNER:_______________________________________ DATE:__________________________
WITNESS _______________________________________________DATE
____________________________
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