Surrender Form

Name of Applicant *

First

Last

Name of Owner *

First

Last

Owner's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Owner’s Home Phone

Owner’s Work Phone

Owner’s Cell Phone

Owner's Email *

Email

Confirm Email

Is there a co-owner? *

Yes
No

Name of Co-Owner *

First

Last

Co-Owner's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Co-Owner’s Home Phone

Co-Owner’s Work Phone

Co-Owner’s Cell Phone

Co-Owner’s Email Address *

Email

Confirm Email

Golden's Information

Name of Golden *

Age of Golden *

Origin of Ownership *

Length of Ownership *

Purebred? *

Yes
No

What is the breed mix? *

Sex of Golden *

Male
Female

Neutered? *

Yes
No

Spayed? *

Yes
No

Weight *

Color *

Microchip Number

Microchip Company

Medical Information

Name of Veterinary *

Veterinary's Phone Number *

Any Veterinary Specialist(s) seen? *

Yes
No

Name of Veterinary Specialist *

Veterinary Specialist's Phone Number *

Purpose of Specialist? *

If more than one specialist seen, please give details below including specialist name, phone number and purpose.

Date of Last Rabies Vaccination *

Date of Last DHPP Vaccination *

Date of Last Bordetello Vaccination *

Date of Last Heart Worm Check *

Brand of Heart Worm Prevention Given *

Date Last Heart Worm Preventative Given *

Brand of Flea Prevention Given *

Date Last Flea Prevention Given *

Any medical problems such as allergies, frequent ear infections, dental, fur loss, skin infections, etc.? *

Yes
No
Don't know

Please explain medical problems. *

Is the dog on any medications, supplements, etc.? *

Yes
No
Don't know

Please list medications, supplements, etc. *

Brand of Dog Food *

Amount of Dog Food Given and How Often *

Social/Behavioral

Has the dog bitten a person? *

Yes
No
Don't know

Please describe circumstances of the biting incident. *

Has the dog bitten an animal such as a cat or dog? *

Yes
No
Don't know

Please describe circumstances of the biting incident. *

Do you own other pets? *

Yes
No

Please describe animal(s), breeds and ages. *

Does the dog get along with female dogs? *

Yes
No
Don't know

Does the dog get along with male dogs? *

Yes
No
Don't know

Does the dog get along with cats? *

Yes
No
Don't know

Is the dog people/toy possessive? *

Yes
No
Don't know

Comments on people/toy possessiveness. *

Is the dog food aggressive? *

Yes
No
Don't know

Comments on food aggression. *

Is the dog storm phobic? *

Yes
No
Don't know

Comments on storm phobia. *

Is the dog afraid of loud noises such as fireworks? *

Yes
No
Don't know

Comments on loud noises. *

Is the dog crate trained? *

Yes
No
Don't know

Is the dog house broken? *

Yes
No
Don't know

Comments on house broken. *

Is the dog accustomed to being alone? *

Yes
No
Don't know

For how long is the dog left alone? *

Comments on not accustomed to being alone. *

Is your dog destructive when alone? *

Yes
No
Don't know

Please describe circumstances. *

Does the dog dig? *

Yes
No
Don't know

Comments on digging. *

Does the dog jump or climb fences? *

Yes
No
Don't know

Comments on jumping/climbing fences. *

Does the dog prefer men or women? *

Men
Women
No preference
Don't know

Name special activities, foods, etc. this Golden enjoys. *

What does this Golden dislike/fear? *

Has this dog had obedience training? *

Yes
No
Don't know

Where did the dog have obedience training? *

Does your dog know basic commands? *

Yes
No
Don't know

What commands are known? *

Do you have children? *

Yes
No

What are the children's ages? *

Release Information

What is the reason for releasing this Golden? *

Can the Golden remain in your home until a suitable foster home has been committed? *

Yes
No
Maybe

How long can the Golden remain in your home? *

Comments on no or maybe staying in your home. *

Are you working with any other source to place this Golden? *

Yes
No

What other sources? *

Are there any known disputes regarding your current ownership of this Golden (i.e. Is there anyone else who might have claim to this dog)? *

Yes
No

Please explain dispute. *

Any other comments?

How did you hear about GREAT?

Photograph of Golden

Please upload a picture of the Golden Retriever to be surrendered. You will also need to provide the Veterinary Records if this dog is selected to come into GREAT Rescue.

Terms of Surrender

Thank you for the confidence you have placed in GREAT Rescue of NE Florida Inc, also known as GREAT and GREAT Rescue by allowing us to re-home your beloved Golden Retriever. We understand this is a difficult decision and we assure you that we will do our best to find a wonderful, loving and responsible home for him/her. Please understand that this surrender is irrevocable and once your Golden Retriever is surrendered, GREAT will hold the title to your Golden Retriever and GREAT will have the sole right and authority to make all decisions regarding your Golden Retriever. Once surrendered, your Golden Retriever will not be returned.

Name of Surrenderer *

First

Last

Name of Co-Surrenderer *

First

Last

Surrender Agreement *

I/We Acknowledge and Agree.

I/we acknowledge that I/we have read and answered the above questions to the best of my/our ability, confirm that this Golden Retriever is owned by me/us and will abide by the terms of this surrender. I/we understand this surrender is irrevocable and I hereby renounce any and all claims to the above described Golden Retriever. It is my understanding that G.R.E.A.T. Rescue of NE Florida, Inc. and those who volunteer on its behalf are in no way liable whatsoever in any regard now or hereafter concerning the surrender of this Golden Retriever.

Date / Time of Submission *

Date

Time

Captcha *

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Submission Notes

A CONFIRMATION PAGE WILL APPEAR UPON SUCCESSFUL SUBMISSION. IF AFTER CLICKING SUBMIT, ONE OR MORE ERRORS ARE FOUND, THE PAGE WILL SCROLL UP TO THE FIRST ERROR AND THE ERROR MESSAGE "This field is required." WILL APPEAR. PLEASE CORRECT ANY ERRORS AND SUBMIT AGAIN. IF YOU STILL HAVE PROBLEMS, PLEASE SEND AN EMAIL TO info@greatrescue.org TO REQUEST AN ELECTRONIC VERSION OF THE FORM.