Owner Relinquishment Form
Please be sure you are serious about relinquishing your dog
before involving the program's time and energies.
Houston
Sheltie Sanctuary, Inc.
PO Box 840235
Houston, TX 77284-0235
FAX: (281) 859-0146
Thank you for entrusting your precious Sheltie to our rescue
program so that he or she may have a new life. We realize there are many
good reasons for relinquishment and respect those decisions. Giving your dog
this opportunity is an act of love, and you are definitely doing the right
thing. Some owners fear that we will put down their dogs when they come
into rescue. Please rest assured: we are a dedicated "no kill"
rescue program for Shelties who need us, and we love all our dogs. Our
mission is to care for your dog, and find him or her the best family
possible for a great match.
I,
__________________________________________________, certify that I am
the sole and legal owner of this Sheltie and hereby surrender to Houston
Sheltie Sanctuary, Inc. Rescue Program the Sheltie known as
_________________________.
I hereby turn over full ownership and responsibility as of this date:
_____________________. I
understand that the contract is effective immediately from this date. I also understand that with this instrument
the dog becomes the property of Houston Sheltie Sanctuary, Inc. Rescue
Program. I will make no attempt to
reclaim or visit this dog. I understand for the
benefit of my dog and out of respect for how busy HSS Volunteers are, there
will be no further contact with HSS by phone or e-mail, or with the adoptive home, and that I can
see how my dog is doing on the HSS web site. I am donating $___________ towards the care and placement of my
Sheltie.
Witness
______________________________
Signature
of Owner
______________________________
Address
of Owner
______________________________
______________________________
Telephone Number of Owner
______________________________
Release of Veterinary Records
Owner's Clinic
_____________________________
I hereby authorize the veterinarian named
herein to release information about me or my pet(s) to Houston Sheltie Sanctuary, Inc. as necessary to evaluate this
application.
PLEASE FILL OUT THE FOLLOWING SECTION
to help us place your dog
(Check all that apply; add any helpful
information where you can.)
Socialization:
Does the Dog Like: Other dogs?_____ Cats?_____
Children?_____ Walks?_____ Riding in the
car?_____ Strangers?_____ Play?_____
Other?__________________________________________________
Has the Dog Been: Housedog? _________ Crated? _______ Tied?_____ Chained? _____ Loose in neighborhood?______
Doghouse?_____ Loose in yard?_____ Yard
at all times? _____ Yard part-time?_____ Other?_________
Habits:
House trained?_____ Howling?_____ Runs?_____ Barking?_____ Finicky eater?_____ Signals to go out?_____ What
Signal?___________________________ Used to collar and leash?_____ Walks nicely on leash?_____ Digging?_____ Escape
artist?_____ Gets out to follow children?_____ Jumps on people?_____ Jumps fences?_____
Chewing?_____ Destructive?_____
Vindictive?_____ Gulps food?_____
Tricks?____________________________________________
Training?____________________________ Titles?_______________________
Other?____________________________________________________________
Temperament:
Friendly?_____ Enthusiastic?_____ Anxious to please?_____
Happy-go-lucky?_____ Suspicious?_____ Cautious?_____
Aggressive?_____ Shy?_____ Reserved?_____ Protective?_____ Very
trainable/Obedient?_____ Hyper?_____ Untrainable?_____
Calm?_____ Adaptable?_____ Stubborn?_____ Lethargic?_____
Inflexible?_____
Can you add anything to describe the dog's general
temperament? ______________________________________________________
Has the dog ever bitten a person? Yes_____ No_____ If yes, explain:__________
__________________________________________________________________
Action taken?_______________________________________________________
Physical Appearance:
Color:___________________ Size:_______________
Medical History:
Veterinarian______________________________________
Address __________________________________________________________.
Phone_________________________
Shots (Which)?______________________
When?_______________________________ Rabies Shot?__________________
Date:__________________ By:_________________________ Expires:_________
Heartworm test?_____
Date:___________,Positive/negative: _______________
Is this dog on heartworm preventative?_______ If so, dose/brand:____________
Fecal exam date:____________ Results:___________________________.
Spayed/Neutered?_________________ Date:_______________
AKC papers?____________
Number:______________
Other medical history (illness, allergies, injuries, physical problems) :
_____________________________________________________________________
Food & Medication: Type of food?_____________________________ Number of feedings per
day?__________ Amount_____________
Type of Medication:____________________________________
Dose:_______________.
Reason for giving dog up: _________________________________________
_____________________________________________________________
Items given with Sheltie:
Leash?_____ Collar?_____ Toys?_____ Describe Toys:___________________ Blanket?_____
Crate?_____ Food?_____ Describe Food:__________________
Other: _____________________________________________________________.
(For use by Houston Sheltie Sanctuary, Inc. Rescue
Program)
Volunteer's Name:_________________________________
Phone:____________
Dog taken
to: ______________________________________Phone:____________
Address: __________________________________________Date:_____________
Rescue #________________Date Adopted: ____________AKC
papers?_________
New
Owner_________________________________________________________
Address:___________________________________________________________
Phone:_____________________________________________________________