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Reason for surrendering this dog:


Name & Number of Veterinarian:

What food does this dog eat:

List all medical issues or illnesses:

List all past medical issues or illnesses:

Date last vaccinated:

Date of last rabies shot:

Date heartworm tested:

Heartworm test result:

Date spayed/neutered:

Date of last exam:


      Likes male dogs

      Likes female dogs

      Likes cats

      Likes small children

      Likes older children

      Better with no kids

      Likes men

      Likes women

      Barks while inside

      Barks outdoors

      Digs in the yard

      Destructive inside

      Jumps fences

      Jumps up on people

      Likes car rides

      Likes leashed walks

      Likes being brushed

      Dislikes being brushed

      Guards food or treats

      Takes treats gently

      Needs a fenced yard

      Timid with new people

      Likes toys

      Likes to chew



      Likes to please

      High energy










Was the breeder contacted:

Can they take the dog back:

How many owners has this dog had:

Age of the dog when you acquired him:

Has this dog ever been neglected/abused:

Is this dog used to being indoors or outside:

How many hours per day is this dog alone:

When alone is this dog crated, left loose or left outdoors:

Is this dog crate trained:

How often does this dog have potty accidents in the house:

Does he know basic obedience:

If yes, what commands/words used:

Can this dog walk up & down stairs:

Can this dog walk on hardwood/linoleum:


Microchip #:


Date of Birth:



Coat (Rough/Smooth):


Is this dog a mix:

If yes, what breeds:

Full Name:

Postal Code:


Home Phone:


Cell Phone:



Is this dog protective:

If yes, of whom:

Does this dog growl at strangers:

How does this dog react to knocking at the door:

Has this dog ever bitten or caused injury to a person or another animal:

If yes, please provide details:

Does this dog have any fears (thunder, etc.):

Does this dog chase cars:

Does this dog chase skateboards, bikes, etc.:

How does this dog react to people or other dogs approaching on leashed walks:

Where did you acquire this dog:

Breeder’s name and phone number:

Comments (please add anything you feel a foster family or the eventual new furever family might need to know):

Behaviour & Temperament:

General Information:

Contact Information:

Health & Diet History:

Description of your dog:

Collie Rescue Network: Owner Release & Surrender Form

Important Note:  Completion and submission of this form online IN NO WAY transfers custody or ownership of any dog to the care of Collie Rescue Network.  The purpose of this form is for informational purposes only and to help CRN use the information given here to determine if we are able to accept your dog into the rescue program.  If your dog is accepted into the program, a volunteer will be in touch with your via phone or email. If for any reason your dog is not accepted into the program a volunteer will be in touch with information for alternatives including other rescue groups or shelters in your local area who might be better able to assist you.

Collie Rescue Network reserves the right  to refuse the acceptance of any dog, at any time, for any reason into their rescue program.

Likes, Dislikes and Traits:

Additional Information:

Please allow 3 - 4 days for a volunteer to get in touch with you.

If this is an emergency, please contact us at