Dog Surrender/Return Profile

POSC Tag #

Dogs can't talk, so they can't tell us where or with whom they would like to live. To ensure that his or her new home is a safe, happy and appropriate place for your dog to live, we need you to fill out this form in as much detail as possible. Detailed and honest information from you is crucial to our placement process, so please take the time to fill in this profile with care and accuracy.

If you need more space for an answer, please click here to download the form, print and mail/fax the form to POSC.

Pet Orphans Of Southern California
7720 Gloria Avenue Van Nuys, CA 91406
Phone: (818) 901 - 0190
Fax: (818) 901 - 0011

Undesirable behaviors and medical issues do not necessarily create problems in placement, however, not disclosing those problems definitely does. Dishonest or incomplete responses can undermine the safety and happiness of both your dog and the new adopting family. If there are any questions that are unclear or that you are uncomfortable responding to for any reason, please contact Alexis, Adoptions Coordinator – ext. 103, about the issue.

GENERAL INFORMATION

Today's Date:	Your Name:
Address:	City:	Zip:
Home Phone #:	Work Phone #:
Cell Phone #:	Email:

1. Shelter Arrival Date: 2. Dog's Name: 3. Dog's Age:

4. Sex: Male Female 5. What breed(s) is this dog?

6. Is this dog spayed/neutered (fixed)? Yes No Unsure

7. How long have you had this dog?

8. How/where did you acquire ownership of this dog? (Please check appropriate box and provide details.)


Private breeder	Name and location of breeder: Did you sign a contract with this breeder? Yes No Have you informed the breeder of your inability to keep this dog? Yes No

Shelter	Name and location of shelter:

Pet Store	Name and location of store:

Family Member	Relationship to you (mother, brother, etc.):

Found as a Stray	Please describe the circumstances of finding the dog.

Free Ad in Paper	Please describe the ad.

Other	Please explain:

9. What were you told about this dog when you got him/her?

10. To your knowledge, how many homes has this dog had prior to yours?
0 1 2 3 4 5 More than 5

11. Why are you unable to keep this dog? Please list as many reasons as needed.

12. If your reason involves behavioral problems, how long has the problem been going on?

13. Have you tried to find a home for this dog on your own? Yes No
If yes, explain how/what you did to try and find a new home for the dog.

14. Have you contacted any breed-specific rescue groups for help in finding a new home for your dog? Yes No

15. If we could help you keep your dog, would you like to speak to a staff member today? Yes No
If yes, please make sure you make this wish known.

16. Does this dog have a microchip? Yes No
If yes, what brand?

17. Would you recommend placing this dog in a home with other dogs? Yes No Maybe
Please explain:

LIFESTYLE

18. Please check all the animals that the dog has lived with:

Male Dog(s)	Female Dog(s)	Small Animals (What kind?)
Male Cat(s)	Female Cat(s)	Farm Animals (What kind?)
Other (Please Explain)

19. Describe the dog's behavior around other dogs. Please check all that apply:

Never been around dogs	Friendly/playful	Gentle/submissive
Bossy	Frightened	Roughhouses
Ignores or is indifferent	Aggressive with all dogs	Aggressive with same sex dogs
Adores other dogs	Starts off "on the wrong foot" when meeting other dogs
Has excellent "canine" manners when meeting other dogs
Other (Please Explain)

20. Would you recommend placing this dog in a home with other dogs? Yes No Maybe
Please explain:

21. Describe the dog's behavior around cats. Please check all that apply:

Never been around cats	Friendly/playful	Gentle/submissive
Chases for fun	Chases to harm	Aggressive
Ignores or is indifferent	Respectful	Frightened
Has killed a cat
Other (Please Explain?)

22. Would you recommend placing this dog in a home with cats? Yes No Maybe
Please explain:

23. Where was the dog when no human members of your family were at home?

Free run of the house	Crated	In fenced yard
Invisible fence©	In garage or basement	Outside on a chain or runner
Confined to the kitchen/bathroom
Other (Please Explain):

24. How many hours a day was the dog kept outside alone?

None	Less than an hour
1-2 Hours	2-4 hours
More than 5 hours	Allowed inside only at night
Lived outdoors only
Other (Please Explain):

25. Please explain how the dog was confined to your property when outside:

Fenced yard	Invisible fence©
Tie out, chain or runner	Kennel or enclosure
Dog house	Other (Please Explain):

26. If your dog was kept tied, did he/she ever do any of the following? (Please check all that apply):

Sleep or sit quietly	Dig
Bark	Cry
Howl	Act aggressively towards pedestrians or other animals
Annoy the neighbors	Become tangled in chain or rope
Shiver in cold weather	Pant or suffer heat exhaustion in hot weather
Escape runner or tie out	Pace or exhibit other obsessive behaviors
Climb or jump fence	Slip collar
Other (Please Explain):

27. When your dog was outside, was he/she ever teased or bothered by people or other animals?
Please explain:

28. Does the dog run after cars, bikes, or pedestrians? Yes No
If yes, what will the dog do when he/she gets to them?

29. Please describe any problems you encountered confining the dog:

30. Please list 4-5 places, aside from the veterinarian, that the dog visits on a regular basis:

31. Please describe what a perfect day for your dog would be like. Please be as specific as possible:

32. Has the dog ever been kenneled at a(n)____? Please check all that apply:

Never kenneled	Private boarding facility	Veterinarian	Animal Shelter
How did the dog react to being kenneled?

33. Where does the dog sleep at night? Please check all that apply:

Loose inside home	Confined to one room	In garage
Outside	In child's bedroom	In adult's bedroom
On "people" bed	On dog bed	On couch or chair
Crate	Other (please explain)

MANNERS & TRAINING

34. When you acquired this dog, did you plan to attend training classes? Yes No
Why or why not?

35. Did you actually attend training classes? Yes No
If so, where?

36. What additional training/performance activities did you participate in with your dog? (Please check all that apply)

Agility	Obedience	Flyball
Herding	Fieldwork	Therapy Dog Certification
Schutzhund	Other (please explain):

37. Has the dog ever done any of the following? (pPlease check all that apply):

Growled	Snapped	Bitten
If yes, at whom? (Please check all that apply):
Adult family members	Children family members	Strangers at door
Visiting adults	Visiting children	Vet or groomer
Dogs or people near his/her sleeping area	Dogs in his/her home	Pedestrians
Dogs or people near his/her food	Dogs out of home	People in uniform
Dogs or people in his/her personal space	Wildlife	Neighborhood pets
Please describe the circumstances in detail:

38. Is this dog housetrained? Yes No
If no, please check all that apply:

Urinates inside home daily	Urinates inside home occasionally
Defecates inside home daily	Defecates inside home occasionally

39. Do your dog's housetraining accidents most often happen when (Please check all that apply):

When dog is not closely supervised	When dog is not kept on a schedule
When dog is overexcited	When dog signals to be let out and is ignored
When dog is sleeping	Other (please explain):

40. How have you dealt with this problem? (Please check all that apply):

Paper training	Confined the dog	Kept dog outside
Rubbed nose in it	Yelled at dog	Consulted vet, trainer or shelter
Hit dog	Made dog feel guilty	Acted "mad" at dog
Blamed myself	Read up on housetraining methods
Other (please explain):

41. Can the dog be allowed off-leash (and come when called)? Yes No

42. Did you crate train the dog? Yes No
If yes, how long did the dog spend in the crate each day?

43. Can this dog be left alone in the house for 8 hours a day without issues? Yes No
If no, why not?

44. Is the dog destructive if left alone inside the home? Yes No
If yes, please check all that apply:

Chews woodwork/walls	Chews paper or trash	Consulted vet, trainer or shelter
Chews toys/stuffed animals	Chews clothing/shoes	Chews plants
Chews windows or doors	Chews objects (which objects?)
Other (please explain):

45. Does the dog raid the trash or get into other similar mischief? Yes No

46. Will the dog "steal" unattended food and objects from tables/counters? Yes No
If yes, how have you handled this problem?

47. Please tell us about the desirable tricks and habits you have taught your dog to do. (Please check all that apply):

Basic obedience commands	Walk on a loose leash
Come when called	Play fetch
Shake or similar cute tricks	Ride nicely in car
Get on and off furniture when invited	Take treats gently
Go to his/her bed when asked	Wait for food
Greets visitors politely	Other:

48. Please describe the dog's barking habits (Please check all that apply):

Barks inside	Barks outside	Barks at strangers inside
Barks at strangers outside	Barks at other animals	Barks when home alone
Barks for attention	Barks during play	Barks when lonely
Barks for attention and is rewarded	Rarely barks	Barks in car
Other, please explain:

49. What words does your dog understand and associate with a particular behavior? (Please check all that apply):

Sit	Stay	Down
Heel	Come	Leave it
Drop	Wait	Off
Fetch	Doesn't know any commands	Other (Please explain):

50. How often do you work with your dog on training?

Everday

Several times per week

Once a week or less

Never

51. Please describe the reward system you use:

52. Is the dog permitted to sit and/or sleep on furniture? Yes No
Does (s)he get off furniture when asked without protest? Yes No
If no, please describe behavior:

53: Describe the dog's behavior in the car. (Please check all that apply):

Loves it	Hates it	Tolerates it	Nervous
Afraid, but ok	Calm	Car sick	Protective of car
Destructive	Dog never rides in car	Other (please explain):

54. How does the dog react to being handled or corrected by the collar? (Please check all that apply):

Growls or barks	Offers strong resistance	Cowers or acts frightened
Backs out of collar	Acts calm and accepting	Lies down
Snaps or bites	Yelps or cries	Other (please explain):

55. Does the dog jump up on people when greeting them? Yes No

56. Is the dog constantly underfoot when food is present? Yes No

57. Does the dog beg at the table or in the kitchen? Yes No
If yes, is this behavior rewarded with food? Yes No

58. Is the dog protective or possessive of any of the following? (Please check all that apply):

Of food (to other pets)	Of toys (to other pets)	Of his/her body
Of food (to people)	Of toys (to people)	Of owner/family
Of property	Other (please explain):

59. Describe what frightens this dog. (Please check all that apply):

Men	Women	Babies or toddlers
School-age children	Teenagers	Unpredictable children
Loud voices/yelling	Strangers/visitors	Water
People in uniform	Erratic or sudden movement	Thunder/lightening
Vacuums	Brooms	Veterinarian/groomer
Cars	Fireworks/loud noises
Other (please explain):

60. What undesireable traits does your dog have. (Please check all that apply):

Licks people	Barks for food or attention	Drools
Jumps on people	Runs out door unexpectedly	Wanders away from house or yard
Follows me everywhere	Steals clothing or shoes
Other (please describe):

61. How have you tried to correct or discourage these behaviors?

62. Please describe any additional unappealing traits/habits this dog has, so that a new family is aware of them.

63. Are there any wonderful, special traits or habits that you would like his/her new family to know about? Please describe:

HEALTH & GROOMING

64. Did the dog see a veterinarian on a regular basis (at least once a year)? Yes No

65. How did the dog react to going to the vet? Please explain:

66. Does the dog need to be muzzled at the vet? Yes No

67. Has this dog ever been hit by a car or required surgery? Yes No
If yes, please explain:

68. Has this dog ever been diagnosed or treated for any of the following by a veterinarian. Please Check all that apply:

Thyroid disease	Lyme disease	Heartworm disease
Environmental allergies	Skin allergies	Irritable bowel
Cancer	Arthritis	Hip Dysplasia
Separation anxiety	Lupus	Chronic ear/eye infections
Entroprian/ectropian eye	Cataracts	Heart murmur
Other major illness/condition (explain):

69. Does the dog require any medication on a regular basis? Please list and explain:

70. Does the dog allow you to clip his/her nails? Yes No

71. Does the dog like to be brushed? Yes No

72. Does the dog like to be bathed? Yes No

73. Are there places on the dog's body he/she does not like to be touched, brushed or petted? Please explain:

74. Has the dog ever been professionally groomed? Yes No
If yes, how did the dog behave?

DIET, EXERCISE & PLAY

75. What brand of dog food did you feed?

76. How often did you feed, and how much?

77. Which of the following did you use?

Dry

Wet

Combination

78. Is the dog regularly fed scraps from the table or "people food"? Yes No

79. Does the dog receive "treats" on a regular basis? Yes No
If yes, what kind?

80. Does your dog have allergies or sensitivities to any grains or common food ingredients? Yes No
If yes, which grains or ingredients? Is there a particular type/brand of food or a specific feeding regimen that has helped?

81. Are there any comments you would like to add about the dog's diet?

82. What are the dog's favorite kinds of toys? Please check all that apply:

tennis ball/rubber ball	frisbee	squeaky toys
rope toys	plastic bottles	shoes
children's toys	sticks	rocks
plush/stuffed toys	shows no interest in toys	Other (Please list/explain):

83. What does your dog do with his or her toys? Please check all that apply:

Carries toys around in mouth	Shreds/tears them apart
Tosses, chases or whips back and forth by himself	Chews them
Tosses, chases or plays tug of war with owner	Retrieves for owner
"Comfort" behaviors (licking, nursing or cuddling)	Buries or hides them
Plays "keep away"	Other (Please explain):

84. Has your dog ever attended training classes? Yes No
If yes, where?

85. What type of exercise does the dog get on a regular (several times a week, at least) basis?

Walking on leash	Running off leash	Accompanies owner jogging
Swimming	Dog park	Accompanies owner walking or hiking
Vigorous play	Plays with other dogs	No exercise at all
Plays w/kids	Plays with adults	Agility or herding work
Other (Please explain):

86. Does your dog get the chance to exercise to the point of getting tired? Never Once a week or less Several times per week

87. What types of play/exercise does your dog seem to enjoy the most? Please list/explain:

88. Describe your dog's play style with people. Please check all that apply:

Plays gently	Does not use teeth or body strength
Plays roughly but stops when told	Jumps and uses mouth in play
Plays very physically	Games quickly escalate out of control
Prefers to chase	Prefers fetch
Just likes to hang out	No interest in playing with people
Tends to herd	Can play with more than one dog at a time
Tends to nip	Cannot play with more than one dog at a time
Respectful Understands That I Am In Control	Other (Please describe):

89. Please describe how your dog plays with other dogs. Please check all that apply:

Plays chase with little or no body contact	Plays hard with hip checks and body slams
Herds or nips others to get them to move	Adapts to whatever play style other dogs have
Shares toys and plays quietly with other dogs	Likes to play with dogs smaller than himself
Likes to play with dogs who are gentle	Will play with all dogs
Has to be in charge in play situations	Barks constantly
Hangs out with other dogs rather than play	Does not enjoy playing with other dogs at all

EXPERIENCE WITH CHILDREN

If your dog has never lived with or regularly visited with children, you may skip forward to the next section. Otherwise, please take the time to complete this section with accurate information so that we can make a safe and responsible placement with children in a new home. Your attention to detail is expected and appreciated.

90. Did your dog live with children in your home? Yes No
If yes, what were the ages of the children?

91. Would you recommend this dog live with children? Yes No
Explain why or why not:

92. Did your home have children as visitors on a regular basis? Yes No
If yes, what were the ages of the children?

93. Would you recommend this dog be placed in a home where children or grandchildren visit on a regular basis? Yes No

94. Were all interactions between dog and child(ren) supervised by an adult? Please explain: Yes No

95. In your opinion, what age children would live happily and safely with this dog?

96. Describe your dog's behavior around children. Please check all that apply:

Never been around children	Friendly/playful	Nervous/frightened
Gentle	Aggressive	Snappy at times
Too active	Indifferent	Excited
Adores children	Watches over children	Actively avoids children
Does not trust children	Unpredictable

97. Describe your children's behavior around the dog the majority of the time. Please check all that apply:

Respectful	Gentle	Nervous/frightened
Active	Played rough	Loud
Ignored the dog	Adored dog	Included dog in everyday activities
Loving	Indifferent	Abusive
Bored with dog	Avoided dog	Treated dog as beloved family member
Unpredictable	Other (Please explain):

98. Please answer these questions about your dog's behavior around children and food:
      Will the dog allow children to touch or handle food and water dishes without getting upset? Yes No
      Does the dog try to take food from children when it is not offered? Yes No
      Did your child regularly offer food/treats to the dog? Yes No
      Will dog take treats offered by child gently? Yes No
      Does the dog hover nearby when your child has food? Yes No
      Have your children fed or watered your dog on a daily basis? Yes No
      Do you have any additional comments about your dog concerning children and food? Please explain:

99. Please answer these questions about children touching or grooming the dog:
      Does the dog accept being brushed or petted by children? Yes No
      Will the dog comfortably accept "examination" by children younger than 6 years old (having ears lifted and tugged,
      having eyes touched, tail held or grabbed, fur "scrunched" or grabbed by children's hands)? Yes No

      Has a child ever tripped over, stepped on, or fallen on your dog? Yes No
      If yes, what was the dog's reaction? Please explain:


      Do you have any additional comments about your dog being touched or groomed by children? Please explain:

100. Please answer these questions about your dog, children and exercise or play:
       Has your dog ever been walked by a child? Yes No
       If yes, please describe the situation and its frequency.


       Has your dog ever been teased or taunted by a child? Yes No
       If yes, please describe the situation.

Please describe your dog's most likely reaction to the following happening around him/her:

a child running:
a child falling down:
a child jumping, hopping, etc.:
a child throwing a ball or toy:
a child yelling or shrieking:
a child swimming:
a child waving arms or other unexpected movements:

Do you have any additional comments concerning your dog exercising or playing around children?

101. Please answer these questions about your dog sleeping or resting around children:
       How will your dog react to a child approaching when he/she is sleeping?


       Did your dog ever regularly sleep in a space accessible by children? Yes No

       Is your dog possessive or guarded about where he or she sleeps? Yes No

       Do you have any additional comments concerning your dog sleeping or resting around children?

WOULD YOU LIKE TO ADD ANYTHING?

102. Are there any additional comments you would like to add about the dog that would be helpful to families considering adopting him or her?

Thank you for taking the time to help an animal in need.

POSC appreciates any monetary donation that can be used towards the care of your surrendered animal.
DONATION AMOUNT: