UKBTR Surrender Form

Questions are essential for records, both statutory and our own, and to aid us in our assessment process; we cannot stress how important it is that ALL questions are answered as truthfully and in as much detail as possible; this is not to judge you but rather ensure we have as much information as possible about every dog surrendered to us to enable us to meet their needs and match them as safely and appropriately as we can with a foster family.

PLEASE BE TRUTHFUL ABOUT ANY BEHAVIOURAL ISSUES. FAILURE TO DISCLOSE INFORMATION PUTS FOSTERERS, CHILDREN AND OTHER DOGS AT RISK OF INJURY

Dog's Name *
Dogs Date of Birth *
Reason for Surrender *
Breed *
Colour
Sex *
Approx Weight in kg *
Neutered: yes/no *
If not neutered, when was their last season
Date last wormed *
Date last flea treated *
Is the dog vaccinated *
Is the Dog Titre Tested
Date of last Titre Test
Date last vaccinated *
Vaccination Card Present *
Vaccination Card Image
HISTORY
Does the dog have any history of Illness/Operations? *
HealthProblems Please add illness details and date of instance
Any known Allergies or Intolerances * eg Allergies to Chicken, Pollen etc
What age was the dog when you got him/her? *
Where did you get him/her from? Breeder/Pound/Rescue *
If Rescue or Pound, which one?
Approximately how many owners has he/she had? *
Do you know much about his/her past? Please provide details *
BEHAVIOUR
Good with children: yes/no *
What age of children?
Good with cats:no/yes *
Is the dog used to Other Furries? * Please state which eg Rabbit, Hamster etc
Aggressive to other dogs? *
Are they aggressive to Male/Female/Both dogs?
In what circumstances / triggers?
How have you dealt with this?
Has your dog ever attacked another dog and caused injury requiring vetenary treatment?
If so, please give details
Aggressive towards humans? *
In what circumstances / triggers?
Has your dog bitten? *
In what circumstances / triggers?
How many times approximately?
Who has your dog bitten? (ie family members / friends / strangers)
Has your dog broken skin?
Did the person who sustained the bite require hospital treatment? if yes, please provide details
Has your dog shown aggression / possessiveness over items such as toys, food, furniture, humans? *
Please give details
Have you ever sought the advice of a dog trainer/behaviourist? *
Please detail advice / opinion given. Please include any behavioural reports and / or details of behaviourist if you have them.
EXERCISE
How often and for how long is your dog exercised? * 1 hour daily, 30 mins every other day etc. Please be as honest as possible so we can give your dog the exercise they are used to.
Is your dog let off lead? *
Recall Please provide details of their Recall. Do they always return? sometimes? rarely?
Is your dog used to being left alone? *
For how long?
Where are they left? Kitchen, Hall, run of whole house etc
Does he/she exhibit any destructive tendencies/separation anxiety? Please give details
What commands does the dog know? sit, wait, stop, lay down, roll over, stay etc
TRAVEL
Does he/she travel well in a car? Do you use a crate / harness. / dog seat in the car? *
FEEDING
What food do you use? * eg Raw, Kibble
Any food allergies eg Allergy to Chicken, Grain Free Food
How much food to you give at each mealtime? *
What times of the day is your dog currently fed? *
SLEEPING ARRANGEMENTS
Where does your dog currently sleep? *
Does he/she currently have their own bed? *
Will you provide their bed? *
Are they crate trained? *
Housetrained: yes/no * Please include details if not reliable
Are they toilet command trained? Which words do you use to encourage them to go to the toilet? eg wee wee, toilet, go potty
Any other information you feel would be useful?
ESSENTIAL
Is your dog Microchipped *
Please enter the Microchip Number
If tattooed: Tattoo Number and Company
In whose name(s) is the dog microchipped? *
Vets Name, Address and Telephone Number
I give permission to above mentioned vets to pass on veterinary records for my dog if requested *
I confirm the above information to be true, accurate and complete * Please sign your name
I have read and understand that this is a legally binding agreement between myself as current owner of the aforementioned dog and UK Boston Terrier Rescue and I hereby transfer ownership of the dog to UK Boston Terrier Rescue *
Forename *
Surname *
Address *
Postcode *
Email *
Telephone Number * Please do not add any spaces to the phone number field
Date *

IMPORTANT Before surrendering your dog to rescue, we would ask you to think long and hard about your reasons and to be absolutely certain that this is the step you wish to take. Once surrendered to us the dog becomes our property legally and the step is irrevocable. In extremely rare circumstances, it may be the opinion of the vet and the behaviourist that the dog is not considered safe to be rehomed. Should that be the case, then UKBTR will, on advice, consider euthanasia. This is ALWAYS an absolute last resort.

UKBTR request a voluntary donation of £30 for a neutered dog, £50 for an unneutered dog, as a donation to reimburse Rescuer a portion of expenses of rescue and rehabilitation. PAYPAL: donation@ukbostonterrierrescue.co.uk BANK: HSBC, UKBTR ACCOUNT NUMBER: 52094045. SORT CODE: 40-09-18 PLEASE QUOTE YOUR DOG’S NAME AS THE REFERENCE AND ADVISE WHICH PAYMENT METHOD YOU USE.

PRIVACY INFORMATION

This privacy information sets out how UK Boston Terrier Rescue (UKBTR) uses and protects any personal information that you provide us.

UKBTR is committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when
using our rescue services, you can be assured that it will only be used in accordance with this privacy statement

Security - We are committed to ensuring that your information is secure. In order to prevent unauthorised access or disclosure, we have put in place
highly secure electronic systems and managerial procedures to safeguard and secure the information we collect.

Controlling your personal information - We will not distribute, sell or lease your personal information to third parties unless we have your explicit permission or are required by law to do so.

You may request details of personal information which we hold about you under the General Data Protection Regulation (GDPR). If you would like
a copy of the information held on you or request we delete your information or would like a full copy of our Privacy Information Policy, please contact Beth Bartlett
at info@ukbostonterrierrescue.co.uk.co.uk.