Release of Ownership Your InformationOwner Name(Required) First Last Co-Owner Name First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Driver's License or State ID NumberGeneral InformationPet Name or Nickname(Required)AKC Registered Name of the DogDog Gender(Required) Male Female Dog Color(Required) Black Black Brindle Grey Grey Brindle Red Red Wheaten Wheaten White Other Dog Breed(Required) Australian Terrier Border Terrier Cairn Terrier Min. Schnauzer Norfolk Terrier Norwich Terrier Scottish Terrier Westhighland White Terrier Mixed Breed If Mix, what is the mix?(Required)Dog Age(Required)Date of Birth (if known): MM slash DD slash YYYY Please supply us with any prior known history of this Dog if you have NOT had the dog since it was a young dog:Dog Weight(Required)Is the Dog overweight or underweight?(Required) Overweight Underweight Just Right Is the Dog microchipped?(Required) Yes No Is the Dog tattooed?(Required) Yes No Does the Dog have any scars or distinguishing features?(Required) Yes No Microchip InformationMicrochip Number(Required)Registry/Microchip Company(Required)Registry / Microchip Company Phone Number:Tattoo InformationLocation of Tattoo(Required)Tattoo Information(Required)Scars or Distinguishing FeaturesPlease describe any scars or distinguishing features:(Required)HistoryWhere did you obtain this Dog?(Required) Pet Store Breeder Adopted from Shelter Rescue Organization Found as Stray Other Diet & TreatsPlease list in detail the brand and type of food you feed (both dry and moist). Include the measured amount fed, feeding time(s), and any special instructions for preparation (such as, mixed with broth or water):(Required)Select the + sign to add additional rowsBrandDry or Moist?Measured Amount FedSpecial Instuctions Add RemovePlease list any treats or special snacks by brand, type and frequency:Select the + sign to add additional rowsBrandTypeFrequency Add RemoveIs the Dog on a special health diet?(Required) Yes No Please explain why the dog is on a special diet(Required)Are any special supplements or vitamins given?(Required) Yes No Please list any special supplements or vitamins(Required)Medical HistoryAre you able to provide a complete medical record on this Dog?(Required) Yes No Veterinarian InformationThe information you provide in this section will be used by Col. PotterCairn Rescue to (i) determine the feasibility of placing the Dog in an adoptive home and (ii) make an informed decision with respect to the allocation of rescue resources then available. Your submission of this Agreement (i) authorizes Col. PotterCairn Rescue to contact the veterinarian listed below and obtain copies of any and all veterinary records for the Dog if Rescue considers it necessary or advisable, and (ii) irrevocably authorizes the veterinarian listed below to provide such records to Col. Potter Cairn Rescue and candidly discuss the health of the Dog with Col. Potter Cairn Rescue.Name of Practice(Required)Name of DoctorAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Inoculations, Preventative Health Care, Treatments and Medical ConditionsInoculations, Preventative Health Care & Treatments(Required)Please select any of the below health care prevention, tests or treatments given to the dog Tested for Heartworms Tested for Internal Parasites (Worms) Heartworm Preventative Worming Medication Flea Preventative Rabies DHLPP Bordetella Lyme Spay/Neuter Teeth Cleaning by a Veterinarian Select AllIf your Dog has not been spayed/neutered, would you be willing to have spay/neuter done prior to surrender or financially aid Rescue in having this done?(Required) Yes No N/A Dog is Spayed or Neutered Already If the Dog's teeth are in need of cleaning, would you be willing to have the teeth cleaned prior to surrender or financially aid Rescue in having this done?(Required) Yes No Heartworm InformationHeartworm Test Date(Required) MM slash DD slash YYYY Heartworm Test Results(Required) Positive Negative Heartworm Preventative Brand(Required)Date Given(Required) MM slash DD slash YYYY Internal Parasites (Worms) InformationInternal Parasites (Worms) Test Date(Required) MM slash DD slash YYYY Internal Parasites (Worms) Test Results(Required) Positive Negative Worming Medication Brand(Required)Date Given(Required) MM slash DD slash YYYY Flea Preventative InformationFlea Preventative Brand(Required)Date Given(Required) MM slash DD slash YYYY Inoculation InformationRabies Inoculation Date(Required) MM slash DD slash YYYY Bordetella Inoculation Date(Required) MM slash DD slash YYYY DHLPP Inoculation Date(Required) MM slash DD slash YYYY Lyme Inoculation Date(Required) MM slash DD slash YYYY Spay/Neuter InformationSpay/Neuter Date(Required) MM slash DD slash YYYY In the event of a female Dog, do you have any documentation to prove that she was spayed; such as a discounted rabies certificate?(Required) Yes No N/A – Male Dog Teeth Cleaning InformationMost Recent Teeth Cleaning Date(Required) MM slash DD slash YYYY Conditions | Disease InformationPlease select any of the following conditions or serious diseases the dog has ever suffered(Required) No conditions or serious diseases ever suffered Blind or Partically Blind Diabetes Cushings or Addison’s disease Thyroid Epilepsy or Seizures Hip Dysplasia Skin Allergies Incontinence Luxating Patella Breathing Difficulties Heart Problems Liver Problems Bladder Problems Digestive Problems Eye Problems Other condition that requires medical treatment or special care Please provide details on any of the conditions or serious diseases selected aboveAny additional health concerns that we need to be aware of(Required)Temperament/TrainingIs the Dog housebroken?(Required) Yes No Is the Dog good with children?(Required) Yes No Is the Dog good with other dogs?(Required) Yes No How is the Dog with cats?(Required) Good with cats Will chase if they run NOT good with cats Not sure Is the Dog good with other pet types?(Required) Yes No Not Applicable – Has not been around other pet types If yes, what other pets(Required)Is the Dog comfortable riding in vehicles?(Required) Yes No Has the Dog had basic obedience training?(Required) Yes No Is the Dog crate-trained?(Required) Yes No Do you have a crate?(Required) Yes No If yes, what size?(Required)Will you be sending the dog in this crate?(Required) Yes No If you do NOT have a crate, will you supply one of appropriate size if necessary?(Required) Yes No Behaviors & CharacteristicsDoes the Dog know any verbal or hand commands?(Required) Yes No Please list any verbal of hand commands. Select the + sign to add additional rows.(Required)Verbal or Hand?Details Add RemovePlease list at least three favorable characteristics a new owner may want to know about the Dog. Select the + sign to add additional rows.(Required) Add RemovePlease list any NEGATIVE characteristics a new owner needs to know about the Dog. Select the + sign to add additional rows.(Required) Add RemoveWhat are three traits you would change about the Dog if you could? Select the + sign to add additional rows.(Required) Add RemoveHas the Dog ever bitten any human being?(Required) Yes No If yes, please provide details:(Required)Please tell us about special toys, games, ways they enjoy being petted, belly or ear rubs, brushing or grooming preferences:(Required)Where does the Dog sleep at night?(Required)Please explain in detail why you are giving the Dog up for possible adoption:(Required)Did you consult with a trainer about this Dog?(Required) Yes No Trainer Name(Required) First Last Trainer Phone(Required)To help us in our efforts to rehabilitate and rehome Dogs, would you be willing to make a taxdeductible donation to our organization if we take your Dog into our program?(Required) Yes No If yes, how much would you be willing to donate?(Required)Terms of Release and SurrenderConsentThis is a legally binding document for the irrevocable surrender of your Dog to Col. Potter Cairn Rescue. Please read it carefully and completely before signing it. Take as much time as you need to fully consider this important decision. If you have any questions, please contact us. Your signature will be required prior to surrendering your Cairn. You must also provide proof of being of legal age in your state to sign contracts. Photographic identification with your current address will be required prior to surrender. For good and valuable consideration, the receipt and sufficiency of which I hereby confirm and acknowledge, I, being over the age of 18 years and of sound mind, hereby irrevocably and unconditionally surrender to Col. Potter Cairn Rescue for placement and adoption, the Dog described in Part I of this Agreement. I understand that by executing this document, I am giving up forever all right, title and interest to such Dog, and that all future decisions regarding the placement of this animal will be made solely by Col. PotterCairn Rescue. I also understand that if this Dog is later found to have such an unpredictable temperament as to be unsuitable for any placement, or if the Dog’s quality of life is substantially impaired, in the opinion of a competent veterinarian, by a chronic, irreversible and/or painful condition, Col. Potter Cairn Rescue may consider euthanasia as a final alternative to adoptive placement. I represent and warrant that the information provided on Parts I and II of this Agreement is the truth to the best of my knowledge and belief and agree (jointly and severally if this Agreement is executed by more than one owner) to hold Col. PotterCairn Rescue, its officers, directors, representatives and volunteers, and any other group or organization that may place this Dog in reliance on the information provided in this Agreement, harmless from any loss or injury resulting from any false information or misrepresentations that I may have submitted or made in this Agreement. I further represent and warrant to Col. Potter Cairn Rescue, its officers, directors, representatives, and volunteers, that I (and if applicable, any other signatories to this Agreement) (i) am/are the sole owner(s) of this Dog (ii) have full power and authority to surrender this animal for adoption (iii) am/are the only person(s) listed as the registered owner(s) of this animal with the AKC (if said Dog is registered). If the Cairn is AKC registered and I have indicated in Part I that I am able to provide AKC Registration Papers for the Dog to Col. Potter Cairn Rescue, I agree to deliver to Col. Potter Cairn Rescue a properly signed transfer of such AK registration papers, omitting the name of the transferee, and hereby designate and authorize Col. Potter Cairn Rescue as my agent and attorney] Please make sure the application is complete before pressing the “Submit” button below. Incomplete applications may be rejected or delayed. By consenting on this document, it is noted that upon delivery of the dog to a Col. Potter volunteer that this will become a legal and binding document.Owner Name(Required) First Last Co-Owner Name First Last CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
