Dog Admissions Form

I hereby certify that I own, have assumed responsibility for or have no knowledge of any other owner of this animal prior to this admission. The information I have given Animal Friends, Inc. about this animal’s age, health and disposition is correct. I have truthfully acknowledged any dangerous behavioral characteristics and any past history of biting or aggressive behavior. If, in the sole opinion of Animal Friends, Inc., any of the above statements are incorrect or if the animal reacts negatively to the shelter environment, Animal Friends, Inc. may notify me to reclaim the animal.

I hereby surrender all my interest in this animal to Animal Friends, Inc. I request and understand that the decisions regarding this animal’s care while sheltered and placement into an appropriate home will be as Animal Friends, Inc. deems advisable. I understand that I have no recourse in these decisions, unless recommended or required by Animal Friends, Inc.

I understand that I must give Animal Friends 24 hours notice if I would like to reschedule my appointment to surrender my pet(s). As Animal Friends has many pets in queue to be admitted, I fully understand and agree that my place in line will be lost and my application purged if I fail to keep my appointment to surrender my pet(s). If, after this event, I would still like to surrender my animal(s), I agree to submit new paperwork for review and wait until a space once again becomes available.

Please acknowledge that you have read and agree to the above statement. I agree
Your Name 
Address 
City 
State 
Zip Code 
Phone Number 
Alternate Phone Number 
Email 
Date 
Dog's Name 
Breed 
Color 
Age 
Sex Male
 Female
Where did you get this dog? If from Animal Friends, please call 412.847.8047. 
If you adopted this dog from another shelter, what shelter? 
Have you contacted this shelter? Yes
 No
Why are you surrendering this dog? 
How long have you had this dog? 
Is the dog spayed or neutered? Yes    No   
Describe your relationship to the dog? Owner
 Friend/caretaker
 Foster owner
 Other (please specify below)
If "Other" please specify here 
Including yourself, list the ages and genders of any other people living in your home 
List any other animals your dog has lived with 
How does your dog typically behave toward the following? (check all that apply) Men your dog knows: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Women your dog knows: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Children your dog knows: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Unfamiliar men: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Unfamiliar women: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Unfamiliar children: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Dogs your dog knows: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Cats your dog knows: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Unfamiliar dogs: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Unfamiliar cats: Never encountered
 Friendly
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Does your dog typically uncontrollably chase or attempt to chase any of the following? (check all that apply) Joggers
 Bicycles
 Skateboarders/roller bladers
 Cars/motorcycles
 Outdoor cats
 Squirrels or other small animals
 Birds
 Doesn't chase
 Other
If "Other" please specify here 
How does your dog usually react when you or another family member does the following? (check all that apply) Bathe: Never tried
 Enjoys
 Allows
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Brush Never tried
 Enjoys
 Allows
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
Wipe feet Never tried
 Enjoys
 Allows
 Afraid
 Shows teeth/growls
 Snaps
 Bites
 None of these
How does your dog usually react when an unfamiliar person approaches or enters the yard or house? Friendly
 Afraid
 Barks
 Shows teeth/growls
 Snaps
 Bites
 None of these
Do you take your dog out to go to the bathroom? Yes (please specify how often below)
 No/paper trained
How many times per day does your dog go out to use the bathroom? 
Does your dog usually have accidents in the house? Yes (please specify how often below)
 No
How often does your dog have accidents in the house? 
Where does the dog spend most of his/her time? Inside the house, runs free
 Inside the house, in cage
 Outside the house, runs free in the neighborhood
 Outside the house, runs free in the yard
 Outside the house, in cage
 Outside the house, tied
 Other (please describe below)
If "Other" please describe here 
How long is your dog left alone (without people) during the week? Never
 1-3 hours
 4-8 hours
 9-12 hours
 More than 12 hours
When your dog is left alone, is he/she ... Outdoors
 Free in home
 Confined to a room
 In a cage
 Other (please describe below)
If "Other" please describe here 
When left alone, does your dog usually show any of the following behaviors? Destroy household items
 Urnate/defecate
 Bark
 Cry
 None of these
When you are home, does your dog usually show any of the following behaviors? Destroy household items
 Urnate/defecate
 Bark
 Cry
 None of these
When your dog plays, does he/she typically ... Jump
 Growl
 Bark
 Bite lightly
 Bite hard
 None of these
What toys does your dog like? Balls
 Frisbee
 Plush
 Squeaky
 Tug Toy
 None
 Other (please describe below)
If "Other" please describe here 
What games does your dog like? Fetch
 Tug
 Chase
 Wrestle
 None
 Other (please describe)
If "Other" please describe here 
Is your dog scared of anything? Yes (please specify below)
 No
What is your dog scared of? 
Please tell us your dog's bad habits 
Is your dog allowed on the furniture? Yes
 No
Where does your dog usually sleep at night? Cage
 Floor
 Dog bed
 Couch
 Owner's bed
 Other (please describe below)
If "Other" please describe here 
What commands does your dog know? No commands known
 Sit
 Stay
 Down
 Come
 Heel
 Give paw
 Other (please describe below)
If "Other" please describe here 
Has your dog ever attended obedience training classes? Yes
 No
Has your dog ever been walk on a leash? Yes
 No
Does your dog have problems riding in the car? Yes (describe below)
 No
 Don't know
If yes, please describe here 
Has your dog escaped your property more than once in the past 6 months? Yes (describe below
 No
If yes, please describe here 
Is there any report of your dog inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)? Yes
 No
 Don't know
Has your dog ever attacked another dog resulting in severe injury or death to the other dog? Yes
 No
 Don't know
Has your dog ever attacked another domesticated animal species (such as cats or livestock but not "small pets" like hampsters, guinea pigs, etc.) resulting in severe injury or death to the other animal? Yes
 No
 Don't know
Check the appropriate box(es) if your dog has ever shown any of the following aggressive behaviors toward: Men Shows teeth/growls
 Snap
 Bite
 None of these
 Do not know
Women Shows teeth/growls
 Snap
 Bite
 None of these
 Do not know
Children Shows teeth/growls
 Snap
 Bite
 None of these
 Do not know
Dogs Shows teeth/growls
 Snap
 Bite
 None of these
 Do not know
Other domesticated animal species (cat, livestock, etc.) Shows teeth/growls
 Snap
 Bite
 None of these
 Do not know
If a snap or bite to men or women was checked, did it take place while breaking up dog fight or while the dog was in severe pain? Yes
 No
If a snap or bite to children was checked, did it take place while breaking up a dog fight or while a dog was in severe pain? Yes
 No
If you checked one or more of the behaviors above, please explain the circumstances of each snap or bite. 
If you checked one of the behaviors above, please answer the following questions (if this does not apply, skip these questions).
Was the aggressive behavior over food? Yes (men)
 No (men)
 Yes (women)
 No (women)
 Yes (children)
 No (children)
Was it over bones, rawhides or chews? Yes (men)
 No (men)
 Yes (women)
 No (women)
 Yes (children)
 No (children)
Was it over toys? Yes (men)
 No (men)
 Yes (women)
 No (women)
 Yes (children)
 No (children)
Was it over stolen objects? Yes (men)
 No (men)
 Yes (women)
 No (women)
 Yes (children)
 No (children)
Was it when the dog was disturbed while sleeping or resting? Yes (men)
 No (men)
 Yes (women)
 No (women)
 Yes (children)
 No (children)
Was it when someone was handling the dog (brushing, handling feet, bathing, teeth brushing, ear cleaning, etc. excluding a reaction to a vet or groomer)? Yes (men)
 No (men)
 Yes (women)
 No (women)
 Yes (children)
 No (children)
Was it when someone entered the house or yard? Yes (men)
 No (men)
 Yes (women)
 No (women)
 Yes (children)
 No (children)
Was it when an adult or child approached or reached toward the dog? Yes (men)
 No (men)
 Yes (women)
 No (women)
 Yes (children)
 No (children)
Does your dog see a veterinarian at least once a year? Yes
 No
If yes, please specify the veterian's name and contact information 
Check the appropriate box(es) if your dog has ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer: Examine (including heart and ears) Never done
 Show teeth/growl
 Snap
 Bite
 None of these
Restrain Never done
 Show teeth/growl
 Snap
 Bite
 None of these
Administer shots Never done
 Show teeth/growl
 Snap
 Bite
 None of these
Trim nails Never done
 Show teeth/growl
 Snap
 Bite
 None of these
Take blood Never done
 Show teeth/growl
 Snap
 Bite
 None of these
Does your dog have to be muzzled at the veterinarian? Yes
 No
Does your dog have any past or present medical conditions? Yes: No
If yes, please describe 
Is your dog currently on any medication or a special diet? Yes
 No
If yes, please describe 
What type(s) of food does your dog eat? Dry
 Wet/canned
 Table scraps
Please feel free to share any additional helpful information 

Dog Admission Form

Animal Friends

Caryl Gates Gluck Resource Center
562 Camp Horne Road | Pittsburgh, PA 15237
Phone: 412.847.7000 | Fax: 412.847.7001
speak@ThinkingOutsideTheCage.org
M-F 11 a.m.-7 p.m. | S/S 10 a.m.-5 p.m.

Copyright 2015 Animal Friends Inc.