First Name*

Last Name*

Email*

Cell Phone

Facility Name*

Contact Person's Name*

Email address that will be used for contact between the Shelter/Rescue and Mo-Kan BC Rescue*

Photos are required of the dog. They must include the following: 1. Front end 2. Back tail 3. Side view. Send to relinquish@mokanbcrescue.org. Your request will NOT be processed unless adequate photos are sent. Do you agree?*

Dog's Name and/or shelter number:*

Gender: *
Choose one: Female, intact Female, spayed Male, intact Male, Neutered

Dog's age in years/months:*

Dog's weight:*

Color*
Choose one: Black/White (with or without tri) Blue Merle, Red Merle Other Red/White (with or without tri)

Purebred or Mix*

Reason for Rescue Transfer Request:*

Is transportation assistance possible?*

Intake Type:*

If Owner Surrender, what was the reason for surrender?

If there is an euthanasia date, when is it?

Has the dog ever bitten a person? If yes, please list circumstances and if medical attention was sought.*

Has the dog ever air snapped or nipped? What where the circumstances around it?*

Does the dog have any known conditions or health concerns?*

Dog's veterinary history (check all that apply.)

If testing was performed and was positive, list what was found and if treatment has started. *

If known, how does the dog respond to kids? What ages? Has the dog lived with kids?*

Does the dog react in a negative way (such as growling, showing teeth, lunging or rigid body with tail and ears still and erect and weight forward over the shoulders) or a fearful way (such as hiding, moving away from, lowered/slow moving tail, head down. tongue flicks or yawning, blinking or averted eyes, cowering, etc.) to any of the following? If known, please check all that apply.

If the dog reacts negatively or is fearful of people (including children) or other dogs, please give details, including a physical description of the person or type of dog. If there is no pattern or the dog does not discriminate, please note that.*

Does the dog respond to storms, fireworks or loud noises (motorcycles, lawn mowers, vacuum, small engines etc.). If yes, please describe the specific past scenarios.*

Does the dog respond to movement, frenetic, rapid or otherwise (eg. bikes, runners, little kids, sweeping, shoveling or raking, etc.)? If yes, please describe specific past scenarios.*

Which of the following would you use to describe the dog. Please check all that apply.

If you marked aggressive, defensive, protective, fearful or dominant, please give examples of when the dog has behaved this way.*

Please list any behaviors that need improving for this dog (ie. barking, jumping on people, recall, fearful of noises, etc.)*

If owner surrender and this info is known, where did the dog predominantly (12 hours or more) live?

If owner surrender and this info is available where did the dog stay when home alone?

What does the dog do when crated? Please check all that apply.

If the dog is upset by crating, please describe the dog's behavior and explain if the dog continuously displays this behaviors or calms down. If the dog calms down, how long does it take?*

Has the dog been tested with other animals? Please check all that apply. If dog testing can be done, please send video by text to relinquish@mokanbcrescue.org

Other Comments:*

I/we hereby affirm that all of the above information is true and correct. *