Hopalong Animal Rescue

Owner Surrender Assistance Application

Today's date
Name
Phone
Dog's name
Dog's age
Dog's size and weight


Has the dog had shots?
Yes No  
Has the dog been spayed/neutered?
Yes No  
Has the dog bitten a human?
Yes No  
Has the dog bitten another animal?
Yes No  
Does the dog guard its food?
Yes No  
Does the dog guard its toys?
Yes No  
Does the dog like children?
Yes No  
Does the dog like other dogs?
Yes No  
Does the dog like cats?
Yes No  
Does the dog have any medical problems
Yes No  
Is the dog on medication?
Yes No  
Is your dog on a special diet
Yes No  
What are your reasons for surrendering your dog to us?
PLEASE EXPLAIN ANY MEDICAL ISSUES. WE REQUIRE COPIES OF ALL MEDICAL RECORDS, TO INCLUDE SHOT RECORDS AND SPAY/NEUTER DOCUMENTS.
I UNDERSTAND THAT HOPALONG ANIMAL RESCUE IS ONLY ASSISTING IN HELPING ME FIND A NEW HOME FOR MY DOG. I ACKNOWLEDGE THAT I AM STILL THE GUARDIAN OF MY DOG, AND AM FULLY RESPONSIBLE FOR THE CARE AND ACTIONS OF MY DOG.
Yes No  
I AGREE TO PAY AN ADMINISTRATIVE FEE OF $50.00. I UNDERSTAND THAT THIS FEE ALLOWS PHOTOS AND A BIO OF MY DOG TO BE ON THE HOPALONG WEBSITE AND OTHER WEBSITES AFFILIATED WITH HOPALONG.
Yes No  
I UNDERSTAND THAT I WILL BE ALLOWED TO BRING MY DOG TO MOBILE ADOPTIONS, SO THAT PEOPLE MAY MEET HIM/HER. I AGREE TO CONTACT HOPALONG’S VOLUNTEER CORRDINATOR THREE DAYS PRIOR TO THE MOBILE ADOPTION TO ENSURE THAT THERE IS ROOM FOR MY DOG AND I.
Yes No  
I UNDERSTAND THAT I AM RESPONSIBLE FOR MY DOG AT ALL TIMES WHILE ATTENDING A MOBILE ADOPTION, AND THAT IF MY DOG DISPLAYS ANY TYPE OF AGGRESSION WHILE AT A MOBILE ADOPTION, I WILL BE ASKED TO LEAVE.
Yes No