DPR of PA Release Form

DPR of PA

RELEASE APPLICATION

Note: We take in only purebred Dobermans.
Your consideration of a donation to DPRPA when you release a dog to us or place the dog with someone we refer to you is greatly appreciated. This donation is tax deductible and will help support our work.

Your Name
Street Address:
City State Zip
Home Telephone Work Telephone Cell Phone
Email
Name of dog to be released

General Information

Why are you relinquishing your Doberman for adoption?

Where and when did you acquire your dog?

Did you meet your dog's parents? No Yes - what were they like?

Is your dog neutered/spayed? No Yes - At what age?

If not neutered/spayed, are you willing to provide that services? No Yes

Color:	Ears cropped?: Yes No	Housebroken? Yes No
Age:	Tail docked? Yes No	Crate trained? Yes No
Sex:	Weight:	Height at shoulders

Feeding frequency and amount:
Brand of food:
Any special diatary requirements?

Obedience trained? No Yes - To what level?
Trainer's name Trainer's phone number

How is your dog confined outdoors (check all that apply)?
Leash Fenced Yard Invisible Fence Other:

Medical History

DHLPP? No Yes - Date:	Rabies? No Yes - Expiration Date:
Bordetella? No Yes - Date:	Dewormed? No Yes - Date:

Heartworm Check? No Yes - Date:

Results

Is your dog presently on heartworm preventative? No Yes - What brand?

Any ongoing medical problems?

Any resolved medical problems?

Is your dog presently on medication or dietary supplementation?
No Yes -What kind?

Veterinarian Information

Veterinarian Name
Street Address:
City State Zip
Telephone

Temperament Information

Answer the following questions as completely as possible. Use the additional comments section below for additional info if necessary.

Has your dog ever bitten anyone (human or animal)? Yes No
If yes, describe the circumstances:

How would you summarize the dog's general attitude?

My dog likes to:

My dog does not like to:

How does your dog respond to...

Cats?
Other dogs?
Children?
Veterinarians?
Strangers?

Have you encouraged your dog to play/act in an aggressive manner? Yes No
If yes, please explain.

How does your dog react when you ...

Approach it while playing with a toy?
Approach it while the dog is sleeping?
Step over it?
Push it off the bed, couch, etc.?
Reach for it?
Put it on a leash?
Touch its feet?
Trim its nails, clean ears or teeth?
Take away a FULL or EMPTY food bowl?
Take away human food that has fallen to the floor?
Push on its rump or shoulders?
Push it onto its back?
Stare at him/her?
Take its muzzle into your hands and shake it?

How does your dog react when...

Someone knocks on the door?
People enter the house?
People leave the house?

He/she is on leash and and another dog approaches:
Does the approaching dog's sex matter?

He/she is on leash and another person approaches:
     When it's corrected while on leash?
     When it's verbally disciplined?
     When it's physically disciplined?
     When someone raises his/her voice to its owner?
    When someone hugs or touches its owner?

Additional info:

Thank you for filling out this questionnaire. Although lengthy, it will aid in evaluating your pet and hopefully enable us to find the best match (should it be adoptable). In addition to the questionnaire, a copy of your pet’s veterinary records, as well as at least one photograph must be returned to DPR of PA before the process can begin. Upon receipt of this completed form, we will contact you with instructions on where to send this additional information.

By checking here, you acknowledge, that the information you have given is truthful and complete, and to the best of your knowledge, your dog has never attacked or bitten a person or animal (except as you have decribed it in this questionnaire).

Please enter your full name as acknowledgement:

The mission of Doberman Pinscher Rescue of PA, Inc. is to rescue and place purebred Doberman Pinschers who display proper temperament and health potential into responsible pet homes, while informing the public about the breed and basic humane care of pets.