SCGRR DOG LISTING AGREEMENT

   
PLEASE USE THE TAB KEY TO MOVE BETWEEN FIELDS TO AVOID SENDING THE FORM PREMATURELY

   
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?



    ____ No
____ Yes


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:

    ____ Male
____ Female


15. Is the dog spayed/neutered?

    ____ Yes
____ No
____ Don't Know


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?

    ____ Yes
____ No


22. If you have AKC papers, will you provide the records?

    ____ Yes
____ No
____ Not Applicable


23. Is the dog microchipped?

    ____ Yes
____ No
____ Don't Know


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?

    ____ Up-to-date
____ Not up-to-date
____ Will provide records
____ Do not have 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:

    _______________________________________________


Date:

    _______________________________________________


Please click on SAVE to submit this form to SCGRR.  A volunteer will contact you shortly.  Thank you!