First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Work Phone
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Cell Phone*

Alt Email

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

What is the name of the Dog?*

Where is the dog located? City and State*

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 will this dog react to cats? *

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 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, the contact person listed above and/or the submitter of this information, am the legal owner or custodian of, or am authorized by the owner or legal custodian of, the above-referenced dog to post this information. I/we certify that all submitted information is correct to the best of my/our knowledge and belief. I/we agree that Great Plains Pointer Rescue, Inc. (GPPR) and/or its designee(s) have the right to refuse, and might not post, any information GPPR provided by me/us for any cause which GPPR and/or its designee(s) deem to be sufficient. In consideration of the acceptance of this information and the opportunity to have this information posted on the Internet by Great Plains Pointer Rescue, Inc. and/or its designees, I/we agree to hold Great Plains Pointer Rescue, Inc. (GPPR), its officers, members, volunteers, coordinators, fostering agent(s), agents, its Internet service GPPR provider(s), Internet presence GPPR provider(s), webmaster(s), and any employees of the aforementioned parties, harmless from any claim for loss or injury which may be alleged to have been caused directly or indirectly to any person or thing by the act of this dog and I/we personally assume all responsibility and liability for any such claim; and I/we further agree to hold the aforementioned parties harmless from any claim for loss of this dog by disappearance, theft, death or otherwise, and for any claim for damage or injury to the dog, whether such loss, disappearance, theft, damage, or injury, be caused or alleged to be caused by the negligence of Great Plains Pointer Rescue, Inc. or any of the parties aforementioned, or by the negligence of any other person, or any other cause or causes. I/we hereby assume the sole responsibility for and agree to indemnify and save the aforementioned parties harmless from any and all loss and expense (including legal fees) by reason of the liability imposed by law upon any of the aforementioned parties for damage because of bodily injuries, including death at any time resulting there from, sustained by any person or persons, including myself/ourselves, or on account of damage to GPPR property, arising out of or in consequence of my/our GPPR provision of information to, sharing information with, and/or participating in any cooperative efforts with Great Plains Pointer Rescue, Inc. including any handling, fostering, health-related support, or transporting by Great Plains Pointer Rescue or any of the aforementioned parties for the above-referenced dog or any other dog or dogs that might be in my/our care or possession, howsoever such injuries, death or damage to GPPR property may be caused, and whether or not the same may have been caused or may be alleged to have been caused by negligence of the aforementioned parties or any of their employees or agents, or any other persons. By clicking the SUBMIT button, I/we assert that we have carefully read and reviewed the foregoing and agree to be bound by all terms and conditions therein. Please sign and date below*