Dog Release Form

RELEASE TO ADOPT/RELEASE OF OWNERSHIP TO GWINNETT HUMANE SOCIETY

Your signature on this form constitutes a release to adopt the animal(s) listed through the Gwinnett Humane Society Placement program.  Please read and answer the following questions carefully, fully, and honestly. 

This information helps us match your pet with the appropriate and hopefully, permanent family.  Any false, inaccurate, or withheld information could cause the new owners to return the pet.  The success of the adoption depends on the details you provide here.       

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Name *

First

Last

Dog Name *

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Email *

Dog Information

Breed *

Second Breed

Age (Yrs, Mon) *

Date of Birth

Gender *Please enter hereFemaleMale

Color/Markings *

Size *Please enter hereFirst ChoiceSecond ChoiceThird Choice

Coat Type *Please enter hereShortLongCurly

How long have you had your dog? *

Where did you aquire you dog? *

How many other people reside with your dog?

Adults (18+)

Teens (12-18)

Older Children (6-12)

Younger Children (0-6)

How many other dogs reside with you

How many other cats reside with you

Dog Behavior

Please describe your dogs behavior using the boxes below

Other Dogs *

• Friendly/Playful
• Gentle/Submissive
• Roughhouses
• Tolerant
• Ignores
• Afraid
• Snappy
• Dominant
• Aggressive
• Fights with
• Too energetic

Cats *

• Friendly/Playful
• Gentle/Submissive
• Roughhouses
• Tolerant
• Ignores
• Afraid
• Snappy
• Dominant
• Aggressive
• Fights with
• Too energetic

Children *

• Friendly/Playful
• Gentle/Submissive
• Roughhouses
• Tolerant
• Ignores
• Afraid
• Snappy
• Dominant
• Aggressive
• Fights with
• Too energetic

Personality (quiet, active, affectionate, etc.) *

Training *

• Housebroken
• Semi housebroken
• Crate Trained
• Leash/Harness Trained

Where is your dog kept?

• Completely indoors
• Indoors; potties outdoors
• Outdoors; sleeps indoors
• Completely outdoors

Is your dog destructive? *Please enter hereNoYes

Does your dog get car sick? *Please enter hereNoYes

Stamina (energetic, mellow, loves to run, etc.) *

How often does your dog have accidents in the house? *

If you have a fence in your yard please describe it

• No fence
• Wood
• Chain Link
• Electric

Animal Destructiveness

• Chews
• Claws
• Digs
• Spays/Marks

Please describe any other behaviour issues not listed

Next

Medical

Is your dog altered? *Please enter hereYesNo

Is your dog chipped? *Please enter hereYesNo

Current rabies shot? *Please enter hereYesNo

Last Heartworm test *

Please upload your dogs latest vaccination records. If you cannot upload them, please bring them to the center when you have your intake appointment.

Click or drag a file to this area to upload.

Release Confirmation

Please confirm why you are giving up this animal? *

• Moving
• Allergies
• Behavioral Problems
• Other

Date / Time *

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