Surrender/Release Form

Wisconsin Boston Terrier Rescue Surrender/Release Form
Name *

First Name Last Name
Today's Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Daytime Phone Number

Area Code Phone Number
Evening Phone Number *

Area Code Phone Number
E-mail address *
Name of dog being surrendered *
Dog's Breed?
Age (approximate) *
Dog's date of birth (if known)
Gender *
Spayed/Neutered? *

Yes No
How long have you had the dog?
Where did you get the dog?
Reason for surrender? *
Medical Information
Date of last DHLP-P
Date of last Rabies vaccination
Any other vaccines given? (please list and give dates given)
Last heartworm test
Result of Heartworm test

Negative Positive
Preventative given? *

Yes No
Brand?
Date of last dose?
List any health conditions (if any)
Is the dog on any medications? If so, please list type and dosage and what they are for.
Current Vet's name *
Current Vet's phone number *

Area Code Phone Number
Current Vet's address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Have you contacted your current vet to give them permission to release the dog's records to WBTR? *

Yes No
Getting to Know the Dog
Is the dog housebroken? *

Yes No
Is the dog good with other dogs? *

Yes No
Is the dog good with cats? *

Yes No
Is the dog good with young children? *

Yes No
Is the dog good with older children? *

Yes No
Is the dog good with men? *

Yes No
Is the dog good with women? *

Yes No
Does the dog have any aggression or behavioral issues? *

Yes No
If yes, please explain:
Has the dog ever bitten anyone? *

Yes No
If yes, please explain:
Does the dog have any fears? *

Yes No
If yes, please explain:
Is the dog crate trained? *

Yes No
If yes, how many hours in the crate at a time?
Where does the dog stay when you are not home? *

Confined to a crate Confined to a certain part of the house Run of the house
Where does the dog sleep at night?
Where does the dog eliminate? (Check all that apply) *

Fenced in yard On a leash on walks On a chain or trolley Loose in the yard
What type of food does the dog eat? *

Wet food Dry food Combination of wet/dry food
What brand of dog food does the dog eat? (Please be specific)
How often does the dog eat? *

Once a day Twice a day Free fed
What commands does the dog know?

Sit Lie down Stay Speak Come Front
Has the dog had any formal obedience training? *

Yes No
If yes, please explain:
What toys does the dog like to play with? *

Kong Stuffed animals Ball Chewies Rope Other
Do you have anything else you would like to share or comment on?
By submitting this form I voluntarily surrender the following animal to Wisconsin Boston Terrier Rescue. I release all rights to this animal and understand I cannot reclaim this animal at any time. I will provide any health records that I have to Wisconsin Boston Terrier Rescue. I further understand that Wisconsin Boston Terrier Rescue may choose to notify me when a successful placement is made, but will not release the name and address of the adopter. I understand this in done in the best interest of the dog. In extenuating circumstances, this requirement may be waived. I further note that I will not be charged a surrender fee, but that Wisconsin Boston Terrier Rescue will accept a donation at this time if I wish to make it.
Make a donation via PayPal (not required)

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USD Donation
Please upload some pictures of your dog.

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Wisconsin Boston Terrier Rescue Surrender/Release Form

Medical Information

Getting to Know the Dog