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OWNER'S INFORMATION

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Last Name:*
Street Address:*
City:*
State:*
Zip Code:*
Phone:*
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Email:*
Driver License Number:*
Issuing State:*
Date of Birth:*

PET'S INFORMATION

Dog's Name:*
Breed or description:*
Choose one:*
Male
Female
Is your dog microchipped?*
Yes
No
Don't know
Microchip Number:*
Is your dog licensed?*
Yes
No
License Number:
How long have you had this dog?*

DOG'S HISTORY

Select all answers that apply. 

1. Why are you giving up this dog?*
Moving
Behavior issues
Not getting along with people
Not getting along with other pets
Other
Please describe:*
2. Does your dog...?*
Dig
Chew
Bark a lot
Escape from the yard
Other
Please describe:*
3. Where is the dog during the day?*
Inside
Outside
Crate/Dog Run
Other
Please describe:*
4. Where is the dog during the night?*
Inside
Outside
Crate/Dog Run
Other
Please describe:*
5. Is the dog potty trained?*
Yes
No
Partially
Unknown
6. When the dog sees other dogs, he/she...*
Plays with them
Barks
Growls
Tries to bite
Depends on the dog
7. When the dog is around children, he/she...*
Plays with
Hides
Barks at
Growls or tries to bite
Depends on the child
8. When your dog sees a stranger, he/she...*
Is friendly
Hides
Barks at
Growls or tries to bite
Depends on the stranger
9. How would this dog react if food or a toy is taken away from him?
Wags tail
Tries to hide item or eats faster
Shows teeth
Growls
Snaps or bites
10. My dog has bitten or shown aggression towards:*
Adult
Child
Cat
Dog
Nothing
Other
Please describe*
11. Rate your dog's play style with people from 1 (Gentle Ben) to 5 (Rough and Tumble):
1 5
2. Rate your dog's play style with other dogs from 1 (Gentle Ben) to 5 (Rough and Tumble):
1 5
13. Has your dog ever shown aggression (bite, growl, snap, shows teeth, etc.) towards a person?*
Yes
No
Maybe
Not sure
14. Has your dog ever injured another animal?*
Yes
No
Maybe
Not sure
15. Has your dog ever gotten a restraint order or been considered aggressive or vicious?*
Yes
No
Maybe
Not sure
16. How does your dog behave with adults?*
Calm
Friendly
Playful
Shy
Protective
Chases
Barks at
Aggressive
Growls
Snaps
Bites
17. How does your dog behave with children?*
Calm
Friendly
Playful
Shy
Protective
Chases
Barks at
Aggressive
Growls
Snaps
Bites
18. How does your dog behave with visitors to your home?*
Calm
Friendly
Playful
Shy
Protective
Chases
Barks at
Aggressive
Growls
Snaps
Bites
19. How does your dog behave with other dogs?*
Calm
Friendly
Playful
Shy
Protective
Chases
Barks at
Aggressive
Growls
Snaps
Bites
20. How does your dog behave with cats?*
Calm
Friendly
Playful
Shy
Protective
Chases
Barks at
Aggressive
Growls
Snaps
Bites
21. How does your dog behave with livestock?*
Calm
Friendly
Playful
Shy
Protective
Chases
Barks at
Aggressive
Growls
Snaps
Bites

TERMS AND CONDITIONS

Each pet will be evaluated first during a consultation with an animal care employee at the time of relinquishment and either accepted or denied into our facility based on medical or behavior.

There is no guarantee that we can accept your pet.

Relinquishment fees are due in full If accepted.

CA Penal Code 597s (A): Every person who willfully abandons any animal is guilty of a misdemeanor.

F&A Code 31253: No Charge for fees pertaining to the dog shall be paid by the board of supervisors.

Date:*
Electronic Signature:*

Participant acknowledges and agrees that by clicking the "Electronic Signature" box on the Relinquishing a Pet | Dog Form, it will act as the Participant's electronic signature to this request and you warrant and represent that the information provided is true and accurate to the best of your knowledge.

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Contact a Shelter

Western Riverside: (951) 358-7387 (PETS)
San Jacinto: (951) 358-7387
Coachella Valley: (760) 343-3644
Blythe: (760) 921-7857

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