Surrendering a Dog

Owner's Name *

Please provide the name of the dog's guardian

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Please indicate if your dog is spayed or neutered. *

"Intact" means your pet has not had surgery to be sterilized.

Intact male (not "fixed")

Neutered male ("fixed)

Intact female (not "fixed")

Spayed female ("fixed")

Does the dog growl during certain circumstances? *

Please check all that apply

During play

Interaction while eating

When meeting people

When meeting other dogs

If approached in own area (i.e. bed, crate, certain room, etc.)

Never

Does your dog need to be muzzled/sedated at the vet? *

No

Yes - muzzled

Yes - muzzled and sedated

Has your dog been diagnosed with any of the following? *

Diabetes

Eplilepsy/Seizures

Skin infections

Ear infections

Tumor

Heart murmur

Thyroid disease

Urinary infection

Arthritis

Allergies

None of the above

Other illness/condition

Is your dog currently on any medication? *

Yes

No

Is the dog housetrained? *

If a dog is housetrained, it means the dog knows to urinate/defecate appropriately outdoors. If a dog is NOT housetrained, it will urinate/defecate in the house or in inappropriate places.

Yes

No

Who has your dog lived with? *

Check all that apply.

Adults

Teenagers

Children (6-12)

Children under 6

Infants

Describe the dog's relationship with children. *

Never been around children

Friendly or playful with children

Tolerated children

Actively avoids children

Unpredictable with children

Growls at children

Nervous/frightened of children

Aggressive towards children

Our suggested surrender fee is $200 per dog/puppy, $100 per cat/kitten, and $50 per small animal. On average, the expense per pet that APCSM incurs is about $60 per day. If these fees are beyond your means, we kindly request that you contribute whatever sum you can comfortably manage. Regardless of your financial capacity, we are committed to helping your pet and we will still provide care for your animal. The APCSM receives no state or federal funding and relies solely on community support and donations. Please indicate what you can give: *

$200

$100

$50

Other