Owner Information

Name:

Street Address:

City/State/Zip:     

Daytime Phone Number:

Evening Phone Number:

Mobile Phone Number:

Best time to contact you:  

Email address:                  

Dog Information

AKC Name:                

Call Name:

AKC Number:

Date of Birth:

How Originally Acquired Dog: 

When Acquired:

If from a Breeder, have you contacted them? N/A Yes No

If from a breeder, please provide their contact information.

Why are you wanting to surrender your German Shepherd?

When does dog have to leave your home?

Are you willing to foster the dog after legally relinquishing the dog to us until a permanent home can be found? No Yes

Dog’s Physical Appearance

Sex: Male Female

Age:

Color:            put general GSD colors as a drop down

Height:   Weight:

Tattoo:                                    

Micro Chip (Make & Number):

Scars, Broken Teeth, etc.:

General overall appearance:                            

Medical History

You must provide AGSR with copies of the dog’s entire medical history file PRIOR to the dog being accepted in to our care.

Veterinarian Name:

Address:

City, State, Zip:                   

Phone:                          

Date of Last Visit for this dog:

Vaccination History  (Dates Last Received)

All Dogs MUST be current on all vaccines, be spayed/neutered and have a current heartworm test PRIOR to acceptance.

Does the dog have any current known medical issue that requires immediate attention?  If yes, please explain.

Is the dog currently in good health?  If not, please explain.

DHLPP:    Rabies: Bordetella:

Date of HEARTWORM Test:             Results: Unknown Positive Negative

Currently on Preventative: No Yes   What Brand:

IS THIS DOG IS SPAYED/NEUTERED? No Yes

Allergies:

Medical Problems:

Medications Required:

Surgeries:

Ever Required Emergency Care:

Current Dog Food:

Current Feeding Schedule & Quantity:

Personality Traits (please check all that apply)

Likes

Dogs   Cats    Other Small Animals    Children    Strangers   Visits to Vet:   Running/Jogging

Crates   Car Rides   Toys/Play   Water   Being Groomed   Traveling

what ages kids has the dog been around safely

Dislikes/Habits

Dog Aggression   Food Aggression    Toy Aggression    Fence Jumping    Escapes Yard

Digging     Separation Anxiety    Barking when left unattended    Destructive    Chewing

Scared of Thunderstorms 

Other Fears/Dislikes:

Other Aggressions:

Temperament Towards Humans

Friendly    Shy    Cautious    Outgoing      Hyper    Energetic    Calm

Anxious    Dominant    Submissive    Submissive Peeing   Obedient    Challenging   

Temperament Towards Other Dogs

Friendly    Shy    Cautious Outgoing    Hyper    Energetic    Calm    Anxious    Dominant

Submissive    Obedient    Challenging

Has dog ever bitten a human?  If yes describe situation, location, when, seriousness of bite, etc.

Has dog ever nipped/shown aggression towards a human?  If yes describe situation, location, when, etc.

Types of Training this dog has had:

house trained obedience trained rides in car

Is the dog crate trained:

Describe any behavioral problems you have experienced.

I would consider this dog to have a energy level.

Dog’s History and Experiences

   House dog     Outdoor Dog    Tied Up    Contained in Open Yard

Has this dog ever been:

Abused    Neglected in any way    Hit by a car    Bred    Allowed on Furniture

Allowed to run off-leash in a NON-fenced in area    Attacked by another animal    Used to wearing a collar   

How does this dog signal to go outside:

What words or commands does this dog know:

Items You Are Sending with the Dog

Toys    Crate/Bed    Food    Collar w/tags    Leash    Medication

Can you foster the dog until placed?

If unable to foster, can you sponsor boarding at rescue rates?

Can you sponsor the dog’s medical treatment?

How long can you keep the dog?

Please be advised we will want to speak with your veterinarian. Please contact your veterinarian to let him/her know we will be calling and that you authorize him/her and/or their representatives to release all records of your dog to us.

 By submitting this form, I hereby swear that:

• The dog hereby discussed is owned by me.

• The above information is true and complete to the best of my knowledge and ability about the dog. 

• I understand that the dog will be further evaluated by AGSR to determine whether or not it is adoptable. 

• All information related to temperament (especially biting incidents) have been disclosed above.

 Type in your name:

Today's Date:

We reserve the right to refuse or deny any application