SILKY TERRIER CLUB OF AMERICA
P.O. Box 1132, Alameda, CA 94051-1132, U.S.A.
Owner Release Agreement
Animal Identification Name Of Dog: Breed: Gender: Spayed/Neutered? Color(s) of Dog: Scars, Tattoos, or Injuries: AKC Registered? If yes, Registration Number:
Veterinary Information Veterinarian Name: Clinic Name: City/town: State & Zip Code: On Heartworm Preventative? Date of Last Heartworm Test: Current Rabies Vaccine? Date of Last Rabies Vaccine: Current DHLPP? Date Of Last DHLPP Vaccine: Current Bordetella? Date Of Last Bordetella Vaccine: Health Problems? If yes, describe:
Animal Care Types or Brands of Dog Food: Frequency of Feeding: How much per feeding?
Behavior Housetrained? Crate Trained? Leash Trained? Barker? Obedience Trained? Sleeps In House? Sleeps On Bed Or Furniture? Gets Along With Cats? Gets Along With Other animals? Chews? Ride Well In Car? Describe dog's behavior with children: Has dog attacked or tried to attack another animal? If yes, describe: Has dog ever bitten or tried to bite a person? If yes, describe:
I agree and understand that I am giving up all rights of possession and ownership of this dog and that I will not be able to redeem said dog at any time nor will I be allowed to know the dog's whereabouts.
RELEASE OF OWNERSHIP
I agree and understand that said dog is now sole property of STCA. I promise that the information that I am giving is accurate and that the STCA will not be held liable or chargeable for any false information or any misrepresentations that I may have submitted on this form. I further agree and understand that STCA will evaluate this dog to determine whether or not the dog being surrendered will be considered "adoptable". The STCA cannot guarantee placement.
Surrendering Owner Information Printed Name Of Previous Owner: Signature Of Previous Owner: Date: Street Address: City: State: Zip Code: Phone Number with Area Code:
Signature of rescue worker: Date:
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