Canine Surrender | Welcome to Wayside Waifs

Canine Surrender Application

Pet Owner Information

Pet Owner Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (please include area code)*

Have you adopted from, donated to, or surrendered another animal to Wayside Waifs in the past?*

Please list any other name(s) you may have used, if applicable (i.e. maiden name, aliases, etc.):*

Pet's Description/Information

Pet's name:*

Nickname(s) for pet:*

Pet's original name (if adopted from Wayside):*

Pet's age:*

Breed:*

Gender:*

Is your pet spayed or neutered?*

Does this pet have a microchip?*

How much does this pet currently weigh?*

Describe this pet's color/markings:*

Where did you get this dog?*

What is the name of the shelter/rescue where you adopted this dog?*

If you selected other, please describe:*

How long have you owned this dog?*

This dog has lived with:*

Women
Men
Children
Cats
Dogs
Other animals

Please explain your selections above (including ages of children, and a detailed description of all other animals this pet has lived with):*

If you ARE NOT the 1st/original owner of this dog, what additional information did the previous owner give you (behavior or medical history)?*

Why are you surrendering this dog?*

Pet's Medical Information

Name of animal clinic you use:*

Primary care veterinarian's name:*

Did this dog receive annual examinations?*

Is this dog current on vaccinations?*

Does your dog require special handling at the vet?*

Please describe experience at vet (ex. must be sedated, tried to bite, fearful, anxious):*

Has this dog seen a vet for anything other than routine vaccinations?*

Please describe the reason(s) for those visits:*

Does this dog have any medical problems or previous injuries that require special attention?*

Please explain (ex. type of injury or diagnosis, current treatments, etc.):*

Is this dog on a special/prescription diet?*

Please list the diagnosis/reason for the special diet:*

Describe meal-time (i.e. how often, time of day, fed alone or around other animals/people):*

Please list all medications/supplements that this dog is currently taking and the dosing instructions:*

Pet's Behavior Information

Has this dog ever bitten a person?*

Please describe what happened before, during, and after the bite:*

Has this dog bitten a person in the last 10 days?*

Did the bite break the person's skin?*

Have you reported the bite to animal control?*

On what date did the bite occur?*

Has your dog ever bitten another animal?*

Please describe what happened before, during, and after the bite:*

Describe your dog's reaction to women:*

Describe your dog's reaction to men:*

Describe your dog's reaction to children (newborn to 5 years old):*

Describe your dog's reaction to children (ages 6 to 12 years old)*

Describe your dog's reaction to children (ages 13 to 18 years old)*

Describe your dog's reaction to people running/biking/skating/etc.:*

Describe your dog's reaction to indoor cats:*

Describe your dog's reaction to outdoor cats:*

Describe your dog's reaction to car rides:*

Describe your dog's reaction to baths/grooming:*

Describe your dog's reaction to nail trims:*

Please describe a typical day/routine for this dog:*

What are some of this dog's favorite activities?*

How would you describe this dog's activity level?*

Where does this dog spend most of its time when you are home?*

Where does this dog spend most of its time when you are NOT home?*

If the dog is crate-trained, which kind of crate?*

Wire/Metal
Plastic
Other

Please describe this crate:*

Where is this crate located in the house?*

Describe this dog's behavior when crated/kenneled:*

When outdoors, the dog is:*

Chained/Tethered
Free-Roaming (No Fence)
In Fenced Yard
In Covered Pen/Run
In Uncovered Pen/Run
Walked On-Leash

How many feet tall is this fence?*

This fence is made of:*

Chain Link
Wire Mesh
Solid Wood
Electric/Invisible
Picket
Other

Describe "other" fence material:*

Will this dog stay within a fenced area?*

How do they try to escape the fence?*

Dig Under
Climb Over
Jump Over
Break Through
Fence Is Not Secure
Unknown

Has this dog ever escaped under other circumstances?*

Gate/Door Left Open
Pulled Free During On-Leash Walk
Darted Out Of Open Door
Other

Please describe the way in which they escaped:*

If this dog has gotten out, do they:*

Come Back When Called
Return On Their Own
Other

Describe what happens when they have gotten out:*

Does this dog have access to the house by a dog door?*

Can this dog be left in the house unsupervised for an extended period (up to 8 hours) at a time?*

Describe the dog's behavior (why they cannot be left alone in household):*

Are other animals with the dog while the dog is left home alone?*

Which other animals are left unattended with this dog while home without people present?*

Is this dog house-trained?*

Does this dog mark (urine) in the home?*

Describe this dog's marking behaviors in the home:*

How long can this dog go without a potty break during the day?*

How long can this dog go without a potty break during the night?*

Where does this dog sleep at night?*

Describe how this dog reacts when food, toys, bones, or other "high value" objects are taken away from them:*

Describe how this dog reacts when approached at its favorite resting/sleeping place in the home:*

Describe how this dog reacts when approached by another familiar pet in the home while they are eating:*

Describe how this pet reacts when approached by another familiar pet while they are playing with/chewing on a favorite toy/bone/treat or other "high value" object:*

Describe how this dog reacts when meeting a stranger while inside the home:*

Describe how this dog reacts when meeting a stranger outside of the home or on a leash:*

Has this dog met another dog while on-leash?*

Describe how your dog reacted (on-leash):*

Has this dog met another dog while off-leash?*

Describe how your dog reacted (off-leash):*

Any objects or situations that this dog dislikes or fears?*

Thunder
Fireworks
Vacuums
Stairs
Other

Describe "other" dislikes/fear(s):*

Have you ever attempted to correct any behavior concerns/problems with training, management, or medical treatment?*

Please describe the behavior you were attempting to correct and what method(s) were used:*

Please provide the name of the trainer, if applicable:*

Were you able to correct the problem behavior?*

Please list any behavioral and/or medical concerns that you have not yet been able to address (with a veterinarian, trainer, or other professional):*

Have you taken any steps to remedy the reason(s) that are causing you to give up this pet?*

Describe the steps you have already taken:*

What training, commands, or special skills does this dog know?*

We understand how difficult it is to surrender a beloved pet. What do you envision their "perfect home" to be like?*

Household Safety/Wellness Information

Has anyone ever threatened to harm/harmed your pet(s)?*

Has anyone ever threatened to harm/harmed you?*

Do you feel safe in your home?*

Please upload (1) image of your pet. Image should be in focus and show the animals face and body.

Max. file size: 50 MB.

Upload image.

Comments

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