Surrender Form Alternatively, you may download our surrender form as a .pdf and mail it in to us. SURRENDER OF DOG FORM * Indicates required fields Upper Midwest Great Dane Rescue Date*: Name of Owner* (please print): Owners email*: Home Phone*: Work Phone*: Other Phone*: Address*: City*:State*: Zip*: Dogs Name*: Dogs Current Weight*: Attach a photo of Dog, if possible: Date Of Birth*: Current Age*: Reason for Surrender*: Color*: Spayed: YNN/A Neutered: YNN/A How long have you owned this dog*? How did you get this dog*? StrayGiftI bred itShelter/RescueBreeder If Shelter/Rescue or breeder, please list which one and a phone number: If you answered breeder, did you sign a contract? YN Have you contacted the breeder? YN Who did you speak to? What date did you speak to him/her? What is the reason they cannot take your Dane back? If you are not the first owner of your dog, what can you tell us about your dog’s past? Is the dog a purebred? YN Is the dog registered? YN If yes which registry and registration number AKC # UKC # CKC # Is the Dane Microchipped? YN If Yes, enter microchip number and where the number is registered Tattooed? YN If Yes what does tattoo say or what number and where is it registered? Vet records Vet Name*: Vet Phone*: Medical Condition: Does the Dane have any health problems, old or current injuries or concerns? YN List All: Is dog on medications or a special diet? YN Food Brand*: Type*: Times the dog eats*: If yes, what and why? Does your dog get ear infections? YN Have skin problems, allergies or hot spots?YN Has your dog’s stomach been tacked?YN Is your dog current on vaccinations? YN Has your dog ever required surgery? YN If yes, please explain: When did your dog last see a veterinarian? Has your dog been tested for heartworm? YN Heartworm Preventative: Heartworm Brand*: Last Dose Date*: Flea/tick preventative Brand*: Last Dose Date*: Does your Dane have a health insurance policy? YN If yes, when does it expire? If prepaid, are you willing to turn it over to UMGDR? YN If yes, please list policy holder, name of insurance company and policy number: Does your dog prefer men or women or get along well with both? Is your dog good with children - toddlers to age 7? YN Children 8 and older? YN If your dog dislikes men, women or children, please explain the behavior in detail: List the ages and sex of the humans that the Dane lived with: List the ages and sex of other animals the Dane lived with: Please answer the following questions regarding the personality of the dog: Check all that apply: very activequietplayful with familyshy to visitorsaffectionatecouch potatoaggressiveguard dog 1. Housetrained? YN How does the dog tell you he/she needs to go outside*? Does your dog have accidents in the house? YN 2. Has the dog had Obedience Training? YN What type of obedience*? 3. Does the dog walk nicely on a leash or pull*? ] 4. When leashed, does your dog lunge at other dogs or people?* YN If yes, please explain the scenario: 5. What kind of collar or harness do you use when walking your dog? 6. How does your dog react if you try to lead him by his collar*? 7. Does your Dane get along with male dogs? YN If no please explain what the Dane does: 8. Does the Dane get along with female dogs?YN If no please explain what the Dane does: 9. Has the Dane been around cats? YN If yes how does the Dane react/play with cats? 10. When does your Dane bark? Is barking excessive*? 11. Has your Dane ever shown aggression toward another animal? YN If yes, please explain: (Some forms of Aggression: growling, snarling, lip curling, biting) 12. Has your dog ever shown any aggression towards humans? YN If yes, please explain: 13. Has your dog ever bitten or attempted to bite anyone?YN If yes, please explain the scenario and the severity of the bite: 14. Is your dog afraid at the vet?YesNo If so, how does s/he display fear? Does your dog need to be muzzled or sedated at the vet? YesNo If so, explain: Has your dog ever bitten or attempted to bite veterinary personnel?YesNo Does your dog guard its food or toys from other dogs/people? YNIf yes, please explain 15. Can you easily take toys, food, rawhides, or bones out of your dog's mouth?YN 16. Describe your Dane when riding in a vehicle*: 17. Where does your dog sleep*? 18. Is your dog used to being crated?YN Is your dog used to Free Roam?YN 19. When your dog is left alone, is it destructive?YN If yes, please explain: 20. Does your dog chew inappropriate items?YN If yes, please explain: 21. Does your dog get into garbage or onto the counter?YN 22. Is your dog playful? YN What are his/her favorite toys/games/activities? 23. How much and what kind of exercise does your dog need each day*? 22. Has your dog ever been swimming?YN If yes, did he/she enjoy the water? 24. Does your dog run away? YN Does your dog Chase cars? YN 25. Does your dog like being groomed?YN Explain: Does your dog like having his/her toenails clipped? YN If no, explain: 27. Is your dog used to being in a (Check all that apply): fenced yardinvisible fenced yardoutside dog runtied up How high is your fence? 28. Does your dog jump fences? YN If yes, how high: 29. Does your dog dig?YN 30. What scares your dog? (e.g. storms, separation, grabbing from behind, other dogs, standing men, young children): 31. What does your dog do when scared*? 32. When your dog is being naughty, what is he/she doing*? 33. Tell us something you love about your Dane: Is there anything else we should know that will help us place the dog in a suitable home? I certify that I am the legal owner of the dog described above and warrant and represent that this dog has never shown signs of aggression towards human beings and further warrant and represent that this dog has not bitten me or any other individual while in my possession. I hereby voluntarily relinquish all claims and ownership of said dog to the organization known as Upper Midwest Great Dane Rescue. ("UMGDR"). I am irrevocably transferring and relinquishing to UMGDR legal ownership of, and micro chip registration/reregistration rights to this dog on the date hereof. I further acknowledge understanding that the dog becomes the property of UMGDR, and that UMGDR will spay/neuter this dog if intact, and will make every effort to place this dog in a new family setting. However, if the dog has serious health issues, serious behavior issues or aggressive issues, UMGDR has the right to euthanize the dog at its discretion. By signing this form, I hereby certify that I have honestly answered all of the above questions, to the best of my knowledge, and have read and completely understand the above release. Signature of Owner: _______________________________________ To be signed at the time the dog is surrendered. This is a legal binding document. The moment you provide a wet signature on this form the dog you are surrendering belongs to UMGDR. If you decide that you want your surrendered dog back you must go through our adoption process which consists of: application fee, application form, reference checks, home visit, and approval from foster family. Once approved you must be the first approved family interested in your surrendered dog. You may be subject to pay adoption fees including any veterinary costs the dog accrues while in our care. We do not guarantee you will get your surrendered dog back. We make no exceptions to this policy or process. Upper Midwest Great Dane Rescue is a volunteer group. We request a donation to cover the cost of veterinary expenses, shots, spay or neuter, kennels, food, transportation, etc. Any amount you can give would be greatly appreciated. Signature of UMGDR Representative to acknowledge receipt of donation in the amount of $ . 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