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1. Name:
2. Address:
3. City:
4. State:
5. Zip Code:
6. Home Phone:
7. Other Phone (identify work, cell):
8. Email Address:
9. Name of Dog:
10. Does anyone else have an ownership interest in this dog?

11. If “yes” please provide the name, address and telephone numbers (business, work and cell phone numbers) of each person:

12. How long have you owned this dog?
13. What is its birth date or estimated age?
14. Gender:
15. Is the dog spayed/neutered?
16. Weight:
17. Color:
18. Markings:
19. Is the dog a purebred? If not, what is the mix?
20. Did you purchase the dog from a breeder? If yes, what is the name of the breeder? If not from a breeder, from whom did you get the dog?
21. Do you have AKC papers?
22. If you have AKC papers, will you provide the records?
   Yes   No   Not Applicable  
23. Is the dog microchipped?
24. If yes, please enter the microchip company and number:
25. Who is the dog's veterinarian (name, phone):
26. Are shots up to date and are you willing to provide records?
27. Does the dog have any physical problems? If so, please describe:
28. Does the dog have any allergies? If yes, please list:
29. Is the dog on medication? If yes, please list types and dosages:
30. Does the dog have obedience training? If so, from what school or trainer?
31. Who in the family does the dog obey?
32. Please list the commands, skills, or tricks the dog obeys or knows:
33. Please check all training that applies:
   Housebroken   Crate-trained   Leash-trained   Paper-trained  
34. Has the dog lived with children? If so, what ages?
35. Has the dog lived with any of the following? (check all that apply):
   Cats   Small Dogs   Large Dogs   Birds   Rabbits   Horses   Other Pets  
36. Where does the dog typically spends his days (check all that apply):
   Loose in House   Crated   Basement   Garage   Fenced Yard   Loose-Unfenced   Tied Out   Kennel Run   Other  
37. Does the dog react poorly to any of the following? Please check all that apply:
   Strangers   Children   Surprises   Loud Noises   Thunder   Walking on Leash   Alone in House   Alone in Yard   Alone in Car  
38. Does the dog do any of the following? (check all that apply):
   Bark excessively   Dig   Jump Fences   Chew   Show Shyness   Fight with Other Dogs   Chase Cats or other Small Animals   Snap or Nip at People   Growl when you Take Away Toys   Growl when you Take Away Food   Show Fear of Children   Show Fear of Men/Women  
39. Has the dog killed or injured other animals? If yes, please explain:
40. Has the dog ever bitten a person? If yes, please describe the incident(s) and include whether medical attention was required or if it was reported to animal control.
41. Who does the dog fear most?
42. Why is the dog up for adoption?
We may not be able to place the dog due to its age, health, physical condition, temperament or lack of training.

Please read, sign and date; I _____________________ hereby make available for adoption through Southern California Golden Retriever Rescue this Golden Retriever named ________________ who is (age) __________. I certify I am the owner of this dog, free and clear of all other interests. I certify that the dog is not possessed of any dangerous or vicious propensities and I have not willfully concealed information about this dog that may indicate such propensities. The information I have provided about this dog is true and complete. I hereby forever release, discharge and agree to hold harmless and indemnify Southern California Golden Retriever Rescue, its Board of Directors, foster home providers, volunteers and 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 of the above named dog, and/or any harm or injury caused by such dog as a result of our offering such dog for adoption, or whatever kind of nature. I further understand and acknowledge that: (1) Despite my offering this dog for adoption, no such adoption may prove possible for this dog because of either terminal illness causing pain or over-aggressiveness toward people that cannot be cured; (2) SCGR Rescue may have no choice but to put this animal to sleep should either of those conditions obtain; and (3) my above release, discharge and agreement to hold harmless and indemnify SCGR Rescue, its foster home providers, volunteers, and agents will also extend to, and cover those events that may occur after I have delivered this animal to SCGR Rescue for adoption through and until such time as this dog is put to sleep if adoption proves not to be possible for either of the above reasons.

Online Signature:
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