First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Work Phone
x

Cell Phone*

Alt Email

Dog Name:*

Breed:*

Sex:*

Weight:*

Date of Birth or Estimated Age:*

Color/Markings*

Microchip:*

Microchip Number (if known):

Reason(s) you are giving up dog:*

HAS YOUR DOG EVER BITTEN OR ATTEMPTED TO BITE A PERSON:*

If yes, please give all details:

HAS YOUR DOG EVER ATTACKED ANOTHER ANIMAL:*

If yes, please give us all details:

House trained:*

Barker:*

Escapes house:*

OK with Cats:*

Crate Trained:*

Digs:*

OK with children:*

Leash Trained*

Jumps Fence:*

OK with dogs:*

Obedience Trained*

Words dog knows:*

Where does dog sleep?*

Brand/type of dog food:*

Fed:

Favorite Treats or Toys:*

Veterinarian name and phone number:*

May we contact your veterinarian?*

Date of last vet visit:*

Up-to-date on Rabies Shot:*

Up-to-date on DHPP (Parvo) shot:*

Up-to-date on Bordatella (Kennel Cough) shot:

On heartworm medication:*

If yes, date of last dose:

On flea preventative:*

If yes, date of last dose:

Other medications dog is currently taking:

Health Problems

Please carefully read the following: With my electronic signature, I certify that I am the sole and legal owner of the dog named above, free and clear of all other interests. I hereby voluntarily surrender said dog to Arizona Boston Terrier Rescue and turn over full ownership and responsibility of this dog to Arizona Boston Terrier Rescue as of this date. I understand that with this instrument this dog becomes property of Arizona Boston Terrier Rescue and they will make the dog available for adoption and place this dog in an adoptive home. I have already or will in a timely manner provide to Arizona Boston Terrier Rescue copies of all available medical and other records for this dog. The information I have provided above about this dog is true and complete and I have not willfully concealed information about this dog. I hereby forever release, discharge and agree to hold harmless and indemnify Arizona Boston Terrier Rescue and its Board of Directors, members, officers, and agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising either directly or indirectly as a result of incomplete or incorrect information provided by me about this dog. I certify that this is my electronic signature:*

Retype your electronic signature:*

It is understood that Arizona Boston Terrier Rescue does not pay for dogs being relinquished to us, nor do we charge a fee or require a monetary donation for taking a dog into our rescue. While this service is free, a donation to help pay for expenses is appreciated but is not required. Enter Date Here:*