OWNER RELEASE FORM - Deacon's Hope Rescue

Dog's Name ( Include nicknames ) *

Gender *

Female

Male

Altered ( Spay/Neutered )

Dog's Age *

Dog's Colors / Pattern *

Does this dog have a microchip? *

Are you the owner of this dog? *

YES

NO

If no, are you acting as an agent for someone? ( Child in school, Military, Parents' Dog )? Please explain. *

How long have you owned this dog? *

How did you acquire this dog? *

Do you have a contract requiring you to return your dog to the breeder/shelter/rescue or other private party? *

YES

NO

If you replied YES to above, please know that there is no shame in returning any animal under contract to do so. It is the right thing to do based on the contractual obligation. If there is a problem with the breeder or agent living up to their contractual obligations , please explain here. *

Where did you get this pet from? Please be specific. *

Where does your dog currently live? *

Inside your home

Outside kennel

Outside in fenced yard

Outside Free Range

Outside on a tether

Is your dog up to date on vaccines and routine veterinary care? *

YES

NO

NOT SURE

Please supply the contact information for the Vet administering vaccines for verification purposes. Please include the name, address and phone number of the vet. For the health of your pet, we would hate to give unnecessary vaccines as well as want to make sure they are up to date. *

What was the date of your dog's last vet visit? *

Does your dog spin in circles, chase shadows, or jump in the air and snap? If so, please define and describe. *

Do you have any registration papers for any registry? *

AKC

ASCA

NSDR

OTHER

Has this dog ever shown any aggression towards humans? If yes, please explain and include any examples. *

Has this dog ever bitten anyone? If yes, please explain. *

Has this dog ever shown any aggression towards other animals? If yes, please explain. *

Is this dog good with other dogs? *

YES

NO

DO NOT KNOW

Is this dog good with cats? *

YES

NO

DO NOT KNOW

Is this dog good with children? *

YES

NO

DO NOT KNOW

Has this dog lived with children? If yes, please list the ages of the children and any positive or negative interactions. *

Does this dog know any commands? *

SIT

DOWN

STAY

LEAVE IT

OFF

OTHER

If other commands are known, please list below. *

Is this dog crate trained? *

YES

NO

DO NOT KNOW

Does this dog ride well in a car? *

YES

NO

DO NOT KNOW

Does this dog have any phobias? Please select all that apply. *

THUNDERSTORMS

LIGHTENING

FIREWORKS

OTHER

If yes to any of the above, please explain and list any remedies tried along with results. *

Does this dog have any health problems that you are aware of? If yes, please explain. *

Does this dog take any medications? If yes, please explain. *

Is this dog on monthly heart worm preventative? If yes, please include when the last dose was given. *

When was this dog last tested for heart worm and what was the result? *

Does this dog respect fencing and boundaries or is he/she a fence jumper or digger? If yes, please describe. *

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

What are this dog's favorite activities? *

Please tell us why you wish to place your dog with our organization. *

RELEASE AGREEMENT: THE UNDERSIGNED, WHO IS/ARE THE LEGAL OWNER(S) OF THE DOG LISTED ABOVE, HEREBY TRANSFER(S) UNTO DEACON'S HOPE RESCUE (DHR) ALL OF MY/OUR INTEREST IN THE DOG LISTED ABOVE, INCLUDING ANY REGISTRATION PAPERS, MEDICAL RECORDS AND ANY MEDICATIONS. IT IS MY/OUR UNDERSTANDING THAT UPON EXECUTION OF THIS RELEASE, DEACON'S HOPE RESCUE WILL HAVE THE AUTHORITY TO DO WHAT IS IN THE BEST INTEREST OF THE DOG AND UPON THE EXECUTION OF THIS RELEASE, THE DOG LISTED ABOVE BECOMES THE SOLE PROPERTY OF DHR, AND I/WE HAVE NO FURTHER RIGHTS, TITLE OR INTEREST IN THE DOG LISTED ABOVE. I CERTIFY THAT I AM THE OWNER, OR THE AGENT OF THE OWNER OF THIS ANIMAL, AND IT IS OWNED FREE AND CLEAR OF ALL OTHER INTEREST. NO OTHER PERSON HOLDS AN OWNERSHIP INTEREST IN THIS ANIMAL. I CERTIFY THAT THIS ANIMAL IS NOT DANGEROUS OR VICIOUS, AND THAT I HAVE NOT WILLFULLY CONCEALED ANY INFORMATION. THE INFORMATION I HAVE PROVIDED ABOUT THIS DOG IS TRUE AND COMPLETE. I HEREBY FOREVER RELEASE AND DISCHARGE MY RIGHTS TO THIS ANIMAL TO DEACON'S HOPE RESCUE. MY SIGNATURE BELOW ALSO SERVES AS MY CONSENT FOR MY VETERINARIAN TO RELEASE RECORDS FOR THIS DOG TO DHR. AT DHR'S DISCRETION, THE BREEDER OF THE DOG DESCRIBED ABOVE MAY ALSO BE CONTACTED. IF THE BREEDER IS KNOWN, PLEASE ATTACH THE INFORMATION TO THIS SHEET.

Please sign (type) your NAME and DATE here. *

I agree to the terms and conditions of this Release Agreement as a binding confirmation instead of a drawn signature. *

Agreed

Please attach medical records here. *

Please attach any breeder or purchase information here. *

Please attach photos or other relevant information here. *