Surrender Questionnaire - Last Chance at Life

Please use this form ONLY regarding pets that need re-homing/surrendering for consideration by LCAL Rescue. Do NOT use the standard contact form on the website, as we will need ALL of these questions answered before considering an animal to take into our care.

PLEASE NOTE: We cannot not take in dogs (or birds) with human or other-animal aggressive behaviors. If the dog you’re needing help with does NOT get along with other dogs or has aggressive behaviors towards children or other adults, we cannot take them into our care. We will do a temperament test as well before consideration for all surrendered animals. Please google a local trainer in your area or reach out to other rescues or SD Humane/Rancho Coastal Humane Soc. ~ LCAL Rescue

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Dog's Name*
Dog's Breed or Breed-Mix*

(i.e. Boxer, Cocker Spaniel, Poodle Mix, Shepherd-Blend, etc.)
Dog's Age*
Sex of your dog*
Male or Female
Spayed or Neutered?*
How did you come into ownership of your dog?*
- Friend/Neighbor/Family Member
- Breeder
- Stray
- Shelter or Humane Society
- Dog Rescue Organization/Group
- Pet Store
- Advertisement
- Born at home
- Name of rescue or shelter:
How long have you had ownership*

(Two days? Two weeks? Two years? etc.)
Including yours, how many homes has this dog had?
Reason for having to re-home/surrender your dog?*
(Describe the reason/reasons you are in need of surrendering your dog. *Please note: We do not take dogs that have dog aggression or human aggression behaviors.)
Is your dog microchipped?*
- Yes
- No
- Unknown
Is the microchip currently registered in your name?*
- Yes
- No
- Unknown
(If someone scans the chip, are you the registered owner?)
Vaccinations your dog is CURRENT on and can provide documentation of
- Rabies
- Distempter/Parvovirus
- Bordatella
- Lyme Disease
- Hepatitis
- Unknown
- Needs vaccinations
Please provide info on vaccinations, even if you don't have records.
Is your pet on a special diet?
- Yes
- No
- Other
Allergies to certain proteins? Raw Diet? Kibble?
Please describe the human family members the dog has lived with.*
- Adult Men
- Adult Women
- Teenager(s)
- Elderly Men
- Elderly Women
- Children/Toddlers
- Other:
Would you recommend placing this dog in a home with children? If so, what ages would be best?*
Your dog lives with or has lived with the following:*
- Male Dog(s)
- Female Dog(s)
- Adult Cat(s)
- Kitten(s)
- Pet Rabbit(s)
- Pet Birds(s)
- Pet Hamster/Gerbil/Guinea Pig(s)
- Chicken(s)
- Other
Describe your dog's behavior when it is around other dogs.*
- Is never around other dogs
- Great with all dogs
- Great with most dogs
- Selective - Good with some but not all
- Ignores or Indifferent
- Alpha - needs to be the top dog (only good with submissive pack members)
- Submissive
- Frightened
- Shy/Timid
- Other
On a TYPICAL day, how many hours is your dog left alone indoors or outdoors?*
- 1-2 hours
- 3-6 hours
- 7-11 hours
- 12-16 hours
Where does your dog sleep at night?*
- Has free roam of the house
- On designated dog bed
- Kids' room
- Gated off laundry room/separate room
- In a crate
- In the garage
- In an outdoor kennel or dog run
- Enclosed patio
- Outdoor doghouse
When no people are home, where does your dog hang out?
- Has free roam of the house
- Confined to one room or designated area
- In a crate
- In the garage
- In an outdoor kennel or dog run
- In a fenced yard
- Tethered to something (indoors or outdoors)
- Other
Is Your Dog Housetrained?*
- Yes, never eliminates in the home
- Only if there's a doggie door
- Only if back door or sliding door is opened
- Unknown - dog is never allowed indoors
- Has occasional accidents when left indoors too long
(Describe potty training/habits & behaviors)
Has your dog ever bitten anyone?*
- Yes
- No
- If Yes, describe circumstances under "Other"
Please describe any/all known health issues and current/past treatments and medications below.*
(Any injuries? Surgeries? Heart condition? Skin? Dietary issues? Special diet? Etc.)
Has your dog completed any formal training?
- No formal training
- Private Trainer -beginner
- Private Trainer -advanced
- Puppy Classes
- In-board Training
- Basic Obedience
- K9 Good Citizen
- Service Dog Trained
- Other
Describe the type of exercise your dog gets on a regular basis*

(Daily dog walks? Dog parks? Doggie daycare? Dog walker? Jogging? Play fetch? Swim? etc.)
Describe any behaviors (likes/dislikes) that would help us in matching/placing your dog with a new family*

(Loves to fetch, frisbees, tug-o-war, wrestle; Dislikes sharing toys or food, dislikes car rides, fireworks, etc.)
Are you prepared/willing to provide our minimum donation of $150 to surrender your dog to our care?*
- Yes, I will donate the $150 minimum surrender donation
- Yes, I plan to donate more than the minimum surrender donation
- No, I cannot financially afford the $150 surrender donation
(Avg. cost for new intakes averages $500 minimum for a healthy dog. Your minimum donation of $150 assists us with initial intake costs/vaccinations/food/care/etc. while waiting for adoption.)
If you have a time limit, what is your deadline (date) that you must surrender your dog?*

(One day? One week? One month?) *Note: We require board of directors approval for surrender/intakes, which can take 1-3 days to obtain review.
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