Contact Information
First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code*
County*
Country
Email*
Home Phone*
Work Phone
Cell Phone*
Alt Email
Text/Pager Email
Name of animal being surrendered:*
What is the animal's date of birth? If not known, please provide approximate age.*
What is the animal's gender?*
Female or Male
Has the animal been spayed or neutered?*
Yes or No
Last known heat cycle, otherwise please enter N/A.*
What is your dog's current weight? *
Current on vaccinations?*
Yes or No
When are the next vaccinations due?*
Date of last heartworm test:*
Is the animal on heartworm preventative? If so, what was the date last given?*
Please provide the name of your vet/clinic/hospital and telephone number. Be sure to call the vet office granting an SRK representative permission to contact if needed. If no current vet, please enter N/A*
Reason for Surrender:*
Where did you obtain the dog? Please include their contact info so we can confirm there is no "return" requirement.*
Is the animal house trained?*
Yes or No
Is animal crate trained?*
Yes or No
Has the animal received any obedience training?*
Yes No
Where does the animal sleep?*
What brand of food is the animal eating? When? How much?*
Animal prefers company of:
Choose all that apply: Men
Women
Children
No preference
Other companion animals
Is the animal gentle with children?*
Yes or No
Is the animal OK with other dogs?*
Yes or No
Is the animal OK with cats or other animals?*
Yes or No
Is the animal microchipped? If yes, please provide microchip provider and chip #.*
Does the animal jump or climb fences?*
Yes or No
Does the animal dig out under fences?*
Yes or No
Do you consider the animal an escape artist?*
Yes or No
Is the animal OK in yard w/o supervision for short periods of time? If so, how many hours?*
If the animal does get out, does s/he respond when called?*
Yes or No
How would you describe the animal's personality?*
Choose:
Dominant
Submissive
Well-adjusted
Socialized
Does the animal bark or howl when left alone?*
Yes or No
Does the animal suffer from separation anxiety?*
Yes or No
Is the animal trustworthy when left alone in the house?*
Yes or No
Does the animal know their name? Also, please list any specific commands the animal knows.*
Please list any of the animal's health conditions or medications. Also, please describe the animal's personality and tell us anything that might help us with placement even those things you think might be negative.*
Have you observed any particular fears, e.g. thunderstorms or behavioral problems, that need to be addressed?*
What are this animal’s favorite things? Playing fetch, playing with and chewing on toys, going for walks, cuddling, playing with other companion animals, etc.?*
By signing and submitting this form, I/we relinquish all rights of ownership of the Brittany listed above, to Stonesriver Kennel Brittanys, and do hereby certify to the best of our knowledge, that this dog has never bitten anyone.
Further, it is understood that Stonesriver Kennel Brittanys was contacted with the express purpose of releasing our rights of ownership. Stonesriver Kennel Brittanys agrees to accept responsibility for the care of said dog until such time as s/he is placed in an appropriate, loving home with approved adopters. It is also explicitly understood that if, on the advice of Stonesriver Kennel Brittany's veterinarian, said dog cannot be rehabilitated to a state of good health then s/he may be humanely euthanized at the sole discretion of Stonesriver Kennel Brittanys.
I/we also certify that the following information provided is as accurate and true as possible.
Your typed signature below serves as your signature*
____________________________________________ Signature
___________________ Date Ex: (01/01/2025)
*=required
Stonesriver Kennel Brittanys
268 Brittany Lane, Manchester, TN 37355, USA