First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Alt Email

I understand that I must answer the following questions so that SSR has proper information regarding your dog. All personal information is for SSR use only and will not be made public. We ask for this information in case we need to contact you or follow up with you on your dog.*

Is your dog a purebred Siberian Husky? If no, please do not fill out this form as we do not and cannot take mixes.*

Dog's Name:*

Male or Female:*
Choose one: Female Male

Age or Date of Birth:*

Is the birthday known or an approximate?*
Choose one: Approximate Known

Weight: *

Coat Color: *

Eye Color:*

Microchip or Tattoo Number:*

If microchipped, what brand?*

Where did you get your dog? Breeder? Adopt from shelter? Adopt from rescue? Took in from bad situation or someone that was rehoming their dog?*

Have you contacted the breeder, shelter or rescue on their policies to return the dog if you need to rehome?*

If yes, what were the results? If no, why?*

Vet's Name and Phone Number: *

Date of Spay or Neuter:*

Date of Last Rabies Shot:*

Date of Last Distemper-Parvo:*

Date of Last Heartworm Test?*

Is the dog currently on heartworm preventative?*

Date of the Last Heartworm Preventative:*

What brand of heartworm preventative do you use?*

Is the dog currently on flea and tick preventative?*

Date of Last Flea and Tick Preventative:*

What brand of flea and tick preventative do you use?*

Does the dog have any known medical problems? If so, please explain.*

Has the dog had any formal training or know any commands?*

Is the dog house trained? If no, please explain.*

Is the dog crate trained? If no, please explain.*

Is the dog leash trained? If no, please explain.*

Does the dog get along with children? If unknown or not all children, specify the ages you know of.*

Does the dog get along with other dogs? If no, please explain.*

Does the dog get along with cats? If no, please explain.*

Does the dog get along with other animals? If no, please explain.*

Has the dog bitten or shown aggression towards adults? If yes, please explain.*

Has the dog bitten or shown aggression towards children? If yes, please explain*

Has the dog bitten or shown aggression towards other dogs? If yes, please explain.*

Has the dog bitten or shown aggression towards cats? If yes, please explain.*

18. On a scale of 1 to 5, (5 being most important), please note how important it is to you that your new family member already has the following traits: Good with babies and small children*
Choose one: 1 2 3 4 5

Has the dog been adjudicated "dangerous", "potentially dangerous", "vicious", "potentially vicious" or a "nuisance"? If yes, please provide details.*

Please describe your dog's temperament and personality:*

Please provide the reason(s) you are surrendering your dog:*

I/we hereby state that I/we are the sole owner(s) of the above-described dog and that there are no other parties that may have a legal interest in this dog. I/we hereby surrender all of my/our interests and ownership rights in such dog to Southern Siberian Rescue and hereby relinquish all claims to said dog. I/we understand that such surrender and release of my/our ownership rights in this dog is irrevocable. I/we state and affirm that the best of my/our knowledge, the said dog has not bitten any human being or animal unless full disclosure is made above. I/we understand and agree that if I/we have not made full disclosure, I/we agree to hold Southern Siberian Rescue harmless and indemnify Southern Siberian Rescue for any damages resulting from the dog’s undisclosed propensity to bite and from any claims by an undisclosed third party with a legal interest in this dog. I/we understand and agree that I/we am/are surrendering this dog to Southern Siberian Rescue of my/our own free will and that such surrender does not constitute a sale. I/we further understand and agree that I/we will receive no money or other compensation as a result of surrendering this dog but that I/we have received a benefit from this listing in that I/we can no longer care for this dog. We consent to the statement above.*

Donation Amount:

I/we are/am the sole owner(s) of the above-described dog and that there are no other parties that may have a legal interest in this dog and hereby release said dog to Southern Siberian Rescue Inc. We consent to the above statement.*

Your name:

Date:*

Signature:*