Canine Surrender ApplicationPet Owner InformationPet Owner Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (please include area code)*Are you the owner of the dog? If not, what's your relationship with the owner?*Have you adopted from, donated to, or surrendered another animal to Wayside Waifs in the past?*-YesNoPet's Description/InformationPet's name:*Pet's age:*Breed:*Gender:*-MaleFemaleIs your pet spayed or neutered?*-YesNoUnknownHow much does this pet currently weigh?*Where did you get this dog?* Found Stray Breeder Family Friend/Acquaintance Adopted from Wayside Waifs Another shelter/rescue (list below) Born at Home Gift Internet If you chose "Adopted from another shelter/rescue", which one?Have you tried reaching out to that shelter? Yes No How long have you owned this dog?*What is the MAIN reason you are surrendering?* New baby Relationship changes (divorce, separation) Health of Owner Temporary placement needed Death of Owner Other pet not accepting Can't afford Allergies Pet's appearance, breed, and/or size No time/overwhelmed Unable to fulfill pet's mental/emotional needs (unrelated to finances) Unable to fulfill pet's medical needs (unrelated to finances) Took ownership without intent to keep Housing Behavior Issues (aggression) Behavior Issues (destructive, behavioral house-soiling) Requesting euthanasia Please explain further if needed (optional):Are you interested in troubleshooting options to keep your pet in the home?* Yes No Maybe How long can you continue to safely care for the pet?*Pet's Medical InformationName of veterinary clinic:*Does your pet have any ongoing or current medical concerns?*-YesNoUnknownIf yes, please describe:Has your pet been diagnosed for anything by a veterinarian?*-YesNoUnknownIf yes, please describe:Is your pet taking any medications and/or on a special diet?*-YesNoUnknownIf yes, list medications or prescribed special diet:If your dog has been seen by a vet, how do they do for medical handling such as blood draws, receiving vaccines, and just generally being handled?*Has your vet ever spoken to you about your pet needing to take medication prior to visiting?* Yes No N/A Behavioral/Personality Questions:How would you describe your pet's personality? (Gentle, friendly, nervous, etc.)*Your dog has lived with:* Men Women Children (age 0-3) Children (age 3-6) Children (age 6-12) Teenagers (age 12-18) Large dog(s) Medium dog(s) Small dog(s) Cat(s) Small mammal(s) Farm animal(s) N/A (stray dog) Has this dog ever bitten a person? If no, skip next 5 questions.*-YesNoDid the bite draw blood?-YesNoHas this dog bitten a person in the last 10 days?-YesNoDate of most recent incident: MM slash DD slash YYYY Describe the incident(s) using as much detail as possible:Has your dog ever bitten another animal? If no, skip next 6 questions.*-YesNoDate of most recent incident: Month Day Year Species of other animal (dog, cat, etc):Did the bite draw blood? Yes No If yes, did the other pet receive medical care for injuries?YesNoUnknownIs the other animal deceased? Yes No Describe the incident using as much detail as possible:How does your dog do when meeting a) strangers in the home and b) strangers outside the home?*How does your dog do with other dogs a) on a leash and b) off leash?*How does your dog react to being left alone?*Has the dog consistently used and currently use a crate while within the home?* Yes No If yes, and if the dog is crate-trained, which kind of crate? Wire/Metal Plastic Other If yes, how does your dog react to being crated?If no, have you tried crating the dog? How did that go?Does your dog escape the property?* Yes No Occasionally If yes, or occasionally, please describe the situation in which your dog escapes and how you've tried to mitigate the issue:When your dog is eating food, treats, or has a special toy and is approached by a person they:* Growl Show teeth Lunge Take the item and walk away Drop item and walk away No reaction When your dog is eating food, treats, or has a special toy and is approached by another dog they:* Growl Show teeth Lunge Take the item and walk away Drop the item and walk away No reaction Personality, Misc. InfoThe following questions are optional to submit this application, but if your pet is accepted we may ask for these questions to be completed before your appointment.In an ideal world, what level of exercise would your dog enjoy getting every day?What are some awesome things about your pet?Does your pet have any bad habits?How does your dog do on car rides?How does the dog act when they see things like bicycles, skateboards, strollers, or cars passing them?What are some things your dog LIKES?What are some things your dog DISLIKES?Is there anything else you want us to know about your pet?Household Safety/Wellness InformationHas anyone ever threatened to harm/harmed your pet(s)?*-YesNoHas anyone ever threatened to harm/harmed you?*-YesNoDo you feel safe in your home?*-YesNoPlease 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.PhoneThis field is for validation purposes and should be left unchanged.
