First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Work Phone
x

Cell Phone*

Alt Email

Please list if this is a shelter transfer or an owner surrender*

What is the name of the Dog?*

What city/state is the dog located in? (Please note, GPPR can only assist with dogs in Iowa and Nebraska) *

Age and Gender:*

Approx weight of dog?*

What breed and color is the dog?

If an owner surrender, what is the name and number of the veterinarian who has seen the dog?

Is the dog spayed or neutered?

Date of Last Heart worm Test and the result:*

Has this dog been tested for Lyme?

Has the dog received a Lyme Vaccine? if so, please list the date of the last vaccination.*

When was the last date the dog received a rabies vaccination? (was it a 1 year or 3 year)

When was the last date the dog received DHPP (also known as DA2PP or DHPPv):

Bordatella Vaccination date:

What other vaccinations has this dog received? (if none, please state so)

Does this dog have a microchip? If so, please list the microchip number and the company of the chip: *

Does the dog have any past or pending health issues? If so; please describe.*

Can you help transport, and if so, how many miles?*

Where did the dog originate from? i/e breeder, stray, etc. *

If the dog was acquired from a breeder, have you contacted them about taking the dog back?

Does the dog have separation anxiety? if yes, please explain:

Does the dog have any type of bite history with humans or other animals?*

How does this dog do with other dogs? (Please include knowledge of large and small canines, males/females)*

How does this dog react to cats? Please explain any exposure. *

How is this dog with children?*

Please describe the current and past living conditions, if known. Is the dog crate trained? House Trained? Lives in an outside kennel? *

Please describe any knowledge of hunting background, being gun shy, etc.

Please describe the personality of the dog overall. Does it know any commands? Other Examples: Affectionate, skittish, nervous, obedient, playful, calm, digger, jumps fences, shy, quiet, barker, hunt trained, etc. *

What is the reason this dog is being surrendered? *

Please provide any other details about this dog that would be helpful to know to find a home, i/e: personality traits, habits, etc.*

What is the date that this dog must be placed by? *

What are the hours available for a volunteer to pick up the dog?*

I/we certify that I/we am the legal owner or custodian of the above dog, or am authorized to act on behalf of the owner/custodian. I/we confirm that the information provided is true and complete to the best of my/our knowledge. I/we understand that Great Plains Pointer Rescue, Inc. (GPPR) may accept, decline, or remove this information at its discretion. I/we agree to release and hold harmless GPPR, its officers, members, volunteers, foster homes, coordinators, agents, and service providers from any claims, demands, or liabilities that may arise from: Any act of the surrendered dog while in my/our care or possession Any loss, injury, damage, or death of the dog once in GPPR’s custody Any injury, damage, or expense (including legal fees) related to my/our participation in the surrender process, including transport, fostering, or veterinary care By submitting this form, I/we acknowledge that I/we have read, understood, and agree to the above terms. (Please e-sign by entering your name and date.)*