First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone*
x

Cell Phone*

Alt Email*

Text/Pager Email*

Dogs Name*

Dog's Sex*

Spayed or Neutered?*
Choose one: No Unsure Yes

Dog's Age*

Does the dog have AKC Papers?*

Dog's Description: Please describe the color and markings (white, white with grey badger face etc.)*

Does the dog have double dew claws:*
Choose one: No Unsure Yes

Where did you obtain this dog?

If you selected "Other Rescue" above, add where you got the dog from*

We understand that no dog is perfect. Please answer the following questions as honestly and accurately as possible so that we may better help in placing this dog in the best possible environment. ----- Is the dog a:

Where does the dog spend the majority of it's time?*

Where does the dog sleep?*

How long have you had the dog?*

How is the dog contained?

If the dog's contained by fence, list height and type:*

Has the dog ever escaped or jumped a fence? (Select all that apply)

If you selected "other" please explain*

If the dog jumped a fence, please indicate height & type of fence (Stockade, picket, wire, vinyl, electric, etc.)*

Will the dog run if loose?

Is the dog crate trained, if yes, please indicate how often, how long, and the last time the dog used the crate*

Is the dog house broken?*

Will the dog walk obediently on a leash?*

Will the dog come when called? (Select all that apply)

Does the dog get along safely with cats? (Select all that apply)

Does the dog get along with other dogs? (select all that apply)

Does the dog get along safely with children? (Select all that apply)

Does the dog get along safely with strangers? (Select all that apply)

When food or treats are present, does the dog (Select all that apply)

What is the dog fed? Please indicate can or dry, brand (Purina ONE, Purina ProPlan, Alpo, whatever was left over from dinner etc.) and quantity and how often.*

Would you describe the dog as:*
Choose one: Sedentary Slightly Active Very Active

Is the dog destructive in the home? (Select all that apply)

Describe any destructive behaviors*

Does the dog become anxious when left alone?*
Choose one: No Unsure Yes

Describe dog's behavior when left alone: (anxious if left in the home alone, anxious if tied outside and you leave, etc.)*

History of aggression towards people?*
Choose one: No Unsure Yes

If yes, describe aggressive behavior:*

Aggressive behavior with other animals?*
Choose one: No Unsure Yes

Describe aggressive behavior with other animals*

Please tell us everything you can about the dog's history, personality traits, training, quirks, etc.*

Dog's current weight*

Please answer the following questions to the best of your ability. If you don't know the date of a vaccination or test, simply say "unsure" or "don't know" Does the dog have: (Select all that apply)

If you checked any of the above boxes, OR if your dog has a medical issue that is not listed, please explain.*

Date of last DHLP vaccination & expiration date:*

Date of last Rabies vaccination & expiration date:*

Date of last DHLP vaccination & expiration date:*

Date of last Lyme vaccination & expiration date:*

Date of last Heartworm test?*

Date given and type of Heartworm Preventative (HeartGard, Ivermectin, Trifexis etc.)*

Date Flea/Tick preventative last applied and type (K9 Advantix, Trifexis, Frontline etc.)*

Date of Last fecal exam for worms and Date/Type of worming (if applicable)*

Veterinarian's Name and Phone Number*

Number of people in your household?*

Ages of children living in the household*

Do you currently own other dogs or pets, if yes, species, breed, Age, Sex, and whether spayed or neutered, etc.*

What resources/training/options have you considered and or exhausted prior to reaching out to our rescue?*

By submission of this information, and my(our) initials in the following box, I(we) attest that the information provided on this application is true and accurate to the best of my(our) knowledge.*