Owner Surrender Form

Blind Dog Rescue Alliance Owner Surrender Form

Blind Dog Rescue Alliance recognizes that, due to unforeseen and unfortunate circumstances, owners of blind or visually-impaired dogs may be faced with the difficult decision of surrendering their dog to rescue.
If you find yourself in such a predicament and have made all reasonable effort to rehome your blind dog, please fill out the following form.
Please note, however, that completion of this form does not guarantee acceptance into our program as blind dogs in shelters are our main priority. It may also take some time to find an available foster compatible with your dog's needs and personality.

* First Name

* Last Name

* Address 1

Address 2

* City

* State

* Postal Code

* Home Phone

Work Phone

Cell Phone

* Email Address

Information on your blind or visually-impaired dog

* Why do you wish to surrender your dog? Please specify.

* What steps have you taken to rehome your dog? Please specify.

* Name of your dog:

* Age or date of birth if known:

* Weight

* Size

* Sex:

Male

Female

* Neutered or spayed?

Yes

No

If no, are you willing to pay to have it done?

* What breed is your dog?

* Have you contacted your dog's breeder or previous owner? If no, why not?

* Does your dog have a registration or microchip number?

Yes

No

If yes, what is that number?

Your dog's temperament and behaviour

* Is your dog

an indoor dog with the run of the house

an indoor dog confined to one area of the house

an indoor dog who is crated

an outdoor dog with a fenced yard

an outdoor dog on a tie-out or chain

an outdoor dog without restrictions

* Is your dog housebroken?

yes

no

* Is your dog leash-trained?

yes

no

Please list any commands your dog knows:

* Has your dog had any formal obedience training? If yes, please describe:

* Is your dog (please check any traits that apply)

* Do you own any other animals?

yes

no

If so, please list:

* Is your dog possessive with treats, toys, or food?

yes

no

* Has your dog ever shown aggression to any person or other animal? If yes, please explain:

* Has your dog ever bitten or snapped at anyone?

yes

no

* Do you feel that your dog adapts well to new situations and surroundings despite his or her visual impairment? Please explain:

Your dog's medical history

Veterinarian's name:

Phone number

* Please advise your vet that we will be calling and give her/him permission to speak with us

* Is your dog current with vaccinations?

yes

no

If no, are you able to pay to have this done?

* Has your dog had a heartworm test?

yes

no

If yes, what was the result?

If no, are you able to pay to have this done?

* Please describe in detail your dog's eye(s) condition:

* Has your dog seen a veterinary opthamologist?

yes

no

* Please add any other information you have about your dog's overall health:

* In the event a foster home is not found within BDRA, I give permission for my name and email address to be networked/crossposted via email, websites and Facebook to help my dog find other rescue. If my dog has not been altered I acknowledge BDRA will be listed as the contact.

Yes

No

* Is there anything you would like to add as we consider accepting your dog into our program?

* Please attach a photo of your dog:

Please attach a second photo of your dog:

* I certify that the information I have provided is true and correct.

I certify that I am the legal owner of the dog described above.

I understand that submission of this form does not guarantee that my dog will be accepted into the Blind Dog Rescue Alliance program.

I agree

Once you hit submit, the attached photos will be uploaded. This might take some time depending on your internet connection speed. Please do not close this window until you get to the confirmation page.

* Indicates Response Required