Form Page: surrenderdd

Application

Name

Address (Street, City, State)

Phone (including area code)

Why do you need to surrender your dog?

I certify that I am the legal owner of (Enter Dog's Name Here:)

Age

Male

Female West Highland Terrier,

, Date of birth

I have owned this dog for how many years?

current on its vaccinations and rabies shots. I hereby consent to Westie Rescue

The Dog is

is not

to obtain any additional

contacting my vet

information concerning this dog's medial care.

To the best of my knowledge, the dog suffers from the following physical symptoms:

This dog is on the following medicine:
(Please list all Names of medicine, dosage, and times per day medication is taken)

The dogs last vet visit was on

Yes

Vet records are provided with this release.

The dog is

This dog has had the following additional surgeries:

is not

altered.

is not

housebroken.

The dog is

What words are used to tell the dog to go potty?

How frequently is the dog let out?

What is the procedure?

How does the dog let you know he needs to go out?

Yes

Is dog is trained?

Yes

Is dog is crated?

Yes

Does dog gets along with other dogs?

Yes

Does dog gets along with cats?

Yes

Does dog get along with children?

hours a day. Does this dog have problems

This dog is accustomed to being alone

Yes

being left alone.

Describe Problems:

allowed to run loose in the house

When the dog is left alone, it is crated

times a day.

The dog is fed

dog food

In my opinion, the best kind of home for this dog would be:

The dog has the following personality traits: (check all that apply)

Barks excessively

Runs Away (Bolts if door is opened)

Friendly

Toy Agressive

Food Agressive

Digs Excessively

Hyper (never sits down)

Active dog

Calm

Prefers men

Kisser

Shy around people

Dog Fetches

Prefers women

Other personality traits:

Other personality comments:

Yes

Has dog bitten/attempted to bite anyone?

If yes, explain:

(Westie doesn't usually take dogs that bite, however, there are a few exceptions)

Yes

Is the dog destructive in any way?

Explanation:

RELEASE

I hereby certify that I am the owner of this dog, free and clear of all other interests and I grant sole ownership of said dog to Westie Rescue of Missouri.

I certify that the information that I am giving to Westie Rescue of Missouri, Inc. is accurate and that Westie Rescue of Missouri, Inc. or its agents will not be held liable or chargeable for any false information, or any misrepresentations that I have submitted on this form.

I hereby forever release, discharge and agree to hold harmless Westie Rescue of Missouri, Inc. and its agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above named dog. I understand that I give up all rights and ownership and that this is a legally binding contract and cannot be rescinded.

I certify that this dog is not possessed of any danger or vicious propensities and has never bitten or attempted to bite any person or animal, and that I have not willfully concealed information about the dog that might indicate such propensities.

I have read the above and understand that by executing this document, I hereby surrender all rights and claims to the animal aforementioned. I further agree that ownership of this dog may be transferred to a new owner without further approval or contact with me.

A SURRENDER DONATION TO HELP DEFRAY RESCUE EXPENSES WOULD BE GREATLY APPRECIATED. DONTATIONS ARE TAX DEDUCTIBLE.

My donation to help the rescue effort is: $

Checks payable to:
Westie Rescue of Missouri
2224 Evergreen Avenue
Des Moines IA 50320

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