Dog Surrender Form

Behavior Checklist
Name:*
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number*
Area CodePhone Number
Email*
example@example.com
Date:*
MonthDayYear
Date
Animals Name:*
Age
Breed*
Upload a picture of your dog.*
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Check the corresponding boxes to inform St Charles Parish Animal Shelter Canine Behavior Specialist as to whether or not your pet has any behavioral concerns worth noting or working on with a professional trainer while in shelter or in foster. Any items marked Yes will be worked on with a trainer. Any items marked Maybe will be evaluated. Please use the back of this sheet to elaborate on any items which you think require additional information
Is your dog an escape artist?*
YesNoUnknown
Does your dog struggle to be confined (in a crate)?*
YesNoUnknown
Is your dog reactive to seeing people when on leash?*
YesNoUnknown
Is your dog reactive to seeing dogs when on leash?*
YesNoUnknown
Is your dog destructive in the home?*
YesNoUnknown
Does your dog get anxious in the car/carsick?*
YesNoUnknown
Is your dog potty trained?*
YesNoUnknown
Is your dog protective of their food?*
YesNoUnknown
Is your dog protective of their toys?*
YesNoUnknown
Is your dog protective of their bed/space?*
YesNoUnknown
Is your dog protective of their siblings (if any)?*
YesNoUnknown
Is your dog protective of their handler?*
YesNoUnknown
Is your dog okay with children 0-2?*
YesNoUnknown
Is your dog okay with children 3-5?*
YesNoUnknown
Is your dog okay with children 5-8?*
YesNoUnknown
Is your dog okay with children 8-12?*
YesNoUnknown
Is your dog okay with children 12+?*
YesNoUnknown
Has your dog ever lived with other dogs?*
YesNoUnknown
Has your dog ever coexisted with dogs smaller than them?*
YesNoUnknown
Has your dog coexisted with dogs larger than them?*
YesNoUnknown
Has your dog ever inured a dog?*
Yes (provide detail)NoUnknown
Has your dog ever lived with cats?*
YesNoUnknown
Has your dog ever injured a cat?*
YesNoUnknown
Has your dog been fearful of children?*
YesNoUnknown
Has your dog been fearful of men?*
YesNoUknown
Has your dog fearful of women?*
YesNoUknown
Has your dog enjoy playing with toys?*
YesNoUnknown
Has your dog enjoyed treats?*
YesNoUnknown
Has your dog ever injured a person?*
Yes (explain)NoUnknown
Notes/Reason for Surrender*
Our first mission is public safety as animal control.
Our second mission is to save the animals left behind as your animal shelter

If an animal is euthanized for aggression/severe medical or pit bull with heartworms & we don’t have funds to treat another at that time, the resident may be a) euthanized & cremated with Agee’s Pet crematorium or b) euthanized at held at -20•C for an organization to pick up that contributes to learning of students to better care for pets medically in the future. If paying for euthanasia for a pet, cremation is the only option we offer. Our hope is no animals are left here, but when they are, we must be responsible in what we put back into the public, efficient with tax dollars and fair to the animals. Animals Euthanized at This Shelter May Be Used for Educational or Research Purposes or to Supply Blood, Tissue, or Other Biological Products. We have done our due diligence to post this according to a bill Humane Society of the United States pushed into the LA legislation July 2019, which doesn’t change how we function, but attempts to alter education and the repurposing of an animal that would have been euthanized anyway by instilling false fears into humans. The real fear is puppies aren’t socialized, dogs are not on heartworm prevention, there’s no medical care, there’s no spay/neuter, families aren’t bonded... and that leads to 150 animals per day here at the shelter. We still have a high standard. We still do what is best for safety and our furry friends, as our community and volunteers appreciate. Thank you for entrusting us and if you ever need anything...we are here!
Relinquishing Receipt for Animal Surrendered to St Charles Parish Animal Control by Owner*
I hereby give St Charles Parish Animal Shelter permission to request all medical history and medical records from my Veterinarian for the animal i am relinquishing.I acknowledge that my signature on his receipt relinquishes all claims of ownership of the animal(s) described. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, suites, or otherwise against St Charles Parish Animal Control with respect to this animal(s). I understand that the St Charles Parish Animal Control will not return this animal to me, once left in its care, under any circumstances, unless otherwise approved by the St Charles Parish Animal Control Director.
Signature*
Clear
Upload a photo of your ID showing proof of residency in St. Charles Parish.*
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Behavior Checklist