Kiko Surrender Request Form

Please provide as much information as possible to ensure a smooth transition to a new home!

How did you hear about us?
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Primary phone number Primary phone number - ### - ### ####
Secondary phone number Secondary phone number - ### - ### ####
Email address
YOUR DOG'S INFORMATION
Name
Reason for surrender
Breed or type of mix
Weight
Gender

Gender Male Female
Date of birth
How long have you owned your dog?
Where did you get your dog from?
Is your dog spayed or neutered?

Is your dog spayed or neutered? Yes No
Is your dog current on vaccinations?

Is your dog current on vaccinations? Yes No
Can you provide your dog's veterinary booklet?

Can you provide your dog's veterinary booklet? Yes No
Does your dog have any current health issues?

Does your dog have any current health issues? No Yes, as detailed below: Yes, as detailed below:
Does your dog have any past health issues?

Does your dog have any past health issues? No Yes, as detailed below: Yes, as detailed below:
Is your dog microchipped?

Is your dog microchipped? No Yes, as detailed below: Yes, as detailed below:
How long is your dog used to being left alone?

How long is your dog used to being left alone? 0-3 hours 3-6 hours 6-9 hours 9-12 hours
Where is the best place to keep your dog when alone?
Where does your dog sleep at night?
Does your dog behave well around food and toys?

Does your dog behave well around food and toys? Yes No, as detailed below: No, as detailed below:
What kind of diet and brand of food are you currently feeding your dog?
How much food and how often are you currently feeding your dog?
Are there children in the home?

Are there children in the home? No Yes, ages as follows: Yes, ages as follows:
How does this dog react around children?
Are there other dog(s) in the home?

Are there other dog(s) in the home? No Yes, age(s), breed(s) and gender(s) as follows:
How does your dog react around other dogs?
Does your dog react well around cats?

Does your dog react well around cats? Yes No Don't know
Does your dog know basic commands?

Does your dog know basic commands? Yes No
Does your dog have a bite history?

Does your dog have a bite history? No Yes, as detailed below: Yes, as detailed below:
Does your dog play rough or use its mouth in an inappropriate manner?

Does your dog play rough or use its mouth in an inappropriate manner? No Yes, as detailed below: Yes, as detailed below:
How does your dog react when scared?
Where is your dog when someone comes to the door?
How long does it take your dog to calm down when someone comes into the home?
Have your neighbours ever complained about your dog?

Have your neighbours ever complained about your dog? No Yes, as detailed below: Yes, as detailed below:
Does your dog have access to a fenced backyard?

Does your dog have access to a fenced backyard? Yes No
Does your dog go off leash and come when called?

Does your dog go off leash and come when called? Yes No
Does your dog get walked and if so, how often and for how long?

Does your dog get walked and if so, how often and for how long? No Yes, as detailed below: Yes, as detailed below:
How does your dog react when meeting dogs on walks?
Does your dog go to dog parks?

Does your dog go to dog parks? Yes No
Where is your dog when the family is eating a meal?
Where is your dog when the family is watching TV?
What is your dog's best quality?
What is your dog's worst quality?
Who does your dog listen to the most and why?
How is your dog best disciplined?
Is your dog trained to be clean in the house?

Is your dog trained to be clean in the house? Yes No, as detailed below: No, as detailed below:
Is your dog trained to go in a crate?

Is your dog trained to go in a crate? Yes No
Is there anything else you think we should know about your dog?
Will your dog be coming with items such as food, crate, bed, toys, leash, collar, etc.? Please note that all items will accompany your dog to its new home.

Will your dog be coming with items such as food, crate, bed, toys, leash, collar, etc.? Please note that all items will accompany your dog to its new home. No Yes, as detailed below: Yes, as detailed below:
A non-refundable $75 surrender donation is requested ($100 for intact and senior dogs), but we will never refuse a dog due to lack of funds.

A non-refundable $75 surrender donation is requested ($100 for intact and senior dogs), but we will never refuse a dog due to lack of funds. Acknowledged
Have you contacted other rescue organizations to surrender your dog?

Have you contacted other rescue organizations to surrender your dog? No Yes, as detailed below: Yes, as detailed below:
By what date does your dog need to leave your home?
I hereby acknowledge that I am the legal owner of this dog, and that the information I have given on this form is accurate. I further acknowledge that the submission of this form does not obligate either myself or Kiko Dog Rescue in any way.

I hereby acknowledge that I am the legal owner of this dog, and that the information I have given on this form is accurate. I further acknowledge that the submission of this form does not obligate either myself or Kiko Dog Rescue in any way. Yes No
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Kiko Surrender Request Form

Kiko Surrender Request Form

YOUR DOG'S INFORMATION