RSPCA Darwin Regional Branch

Dogs and Puppies - RSPCA Darwin Regional Branch

RSPCA NT

Donate via PayPal

Dogs and Puppies

Dog Surrender Application

Step 1 of 9 - Your Details

11%

Comments
This field is for validation purposes and should be left unchanged.
Your Details
First name*
Last name*
Date of birth*
DD slash MM slash YYYY
Address*
Suburb*
State*
Postcode*
Phone number*
Email address*
Driver's license number*
Secondary contact name*
Secondary contact number*
Secondary contact relation*

Your Dog's Details
Dog's Name*
Sex*
Age*
Breed*
Colour*
Is this dog desexed?*
Is this dog microchipped?*
Microchip number*
This field is hidden when viewing the form
Has this dog been vaccinated?*
When was this dog last vaccinated?*
Proof of Vaccination History*
Accepted file types: jpg, gif, png, Max. file size: 40 MB.
This field is hidden when viewing the form
How long have you had this dog for?*
Where did you get this dog from?*
Describe this dog’s personality, temperament and behaviour:*
What is your favourite thing about this dog?*
What are some behaviours or characteristics you dislike about this dog?*
What is the main reason for surrendering this dog?*

Medical Information
When did your dog last visit a vet?*
This field is hidden when viewing the form
Has this dog ever been diagnosed by a vet with a medical condition?*
If yes, what diagnose was given?*
This field is hidden when viewing the form
Do you currently have any health concerns for this dog?*
If yes, please describe in detail*
Example: diarrhoea, skin concerns, vomiting, lumps or coughing.
This field is hidden when viewing the form
Are you aware of any allergies this dog may have?*
If yes, please provide*
This field is hidden when viewing the form
Has there been any previous medical issues, surgeries, serious injuries?*
If yes, please provide*
This field is hidden when viewing the form
Does this dog obsessively chase shadows or its own tail?*
Please list every vet this dog has been taken to*
This field is hidden when viewing the form
By submitting this form, you are consenting to RSPCA Northern Territory requesting this dog's medical history.

Lifestyle & Home Life
What best describes your home environment?*
Who lives in the house with this dog? Please include ages:*
Example: 2 x adults over 18. 3 x children, 4, 8 and 10
Where is this dog usually kept?*
If this dog is left alone, what destructive behaviours do they demonstrate?*
- Chews toys and small items
- Digs holes
- Destroys structural items, such as doors and walls
- Bark, howl or cry for long periods of time
- Desperately tries to escape
- None
How many hours in a day is this dog left by themselves?*
Is this dog toilet trained?*
What does this dog choose to do when left alone?*
How active would you say this dog is?*
What would you say this dog’s obedience level is?*
This field is hidden when viewing the form
How would you describe this dog’s leash behaviour?*
How does this dog feel about baths?*
Does this dog become frightened or distressed by anything?*
If yes, please describe*
Example: Fireworks, storms or loud noises.

Fencing and Containment
Is there a fence at the property that houses this dog?*
What height is the fence?*
How does this dog react to other dogs at the fence?*
This field is hidden when viewing the form
Is this dog muzzled?*
If yes, why:*
This field is hidden when viewing the form
Is this dog chained?*
If yes, why:*
This field is hidden when viewing the form
Has this dog ever escaped from the property before?*
If yes, how does this dog escape?*
How often do they escape?*
Has this dog ever injured itself while trying to escape?*
This field is hidden when viewing the form
Has this dog ever injured itself while trying to escape?*
If yes, please provide details*
This field is hidden when viewing the form
Do you restrain your dog when there are visitors?*
If yes, why:*
This field is hidden when viewing the form

Interaction with Other Animals
Does this dog live with other animals?*
If yes, please provide details of other animals:*
Include species, name, breed, age, gender, and if desexed.
Are the animals housed together or separately?*
Please describe how the animals interact:*
Example: they avoid each other, spend every moment together, co-exist, etc.
Have the animals ever fought?*
If yes, please describe what happened:*
This field is hidden when viewing the form
Has this dog ever shown aggression or been in a fight with a familiar or unfamiliar dog?*
If yes, what happened:*
This field is hidden when viewing the form
What is this dog’s usual behaviour towards familiar and unfamiliar dogs?*
- Friendly
- Fearful
- Aggressive
- Playful
- Selective
- Reactive
- Has never interacted with other dogs
- Unsure
How does this dog interact with cats:*
How does this dog interact with small animals:*
Is this dog comfortable around other animals when being fed?*
If no, describe their behaviour:*
Please describe any unpleasant situations that have occurred with another dog or other animals, both familiar and unfamiliar:*

Interaction with People
How does this dog behave around unfamiliar people?*
- Friendly
- Fearful
- Aggressive
- Shy
- Barks
- Excited
- Doesn't care
Has this dog ever bitten anyone?*
If yes, please describe the incident in detail:*
Example: where did the incident occur, what happened leading up to the bite, where was the person bitten, what medical treatment, if any, was required.
How does this dog behave around children?*
- Friendly
- Fearful
- Aggressive
- Excited
- Doesn't care
- Tolerant
- Excellent
- Unsure
This field is hidden when viewing the form
Has there been any unpleasant situations involving children?*
If yes, please describe:*
This field is hidden when viewing the form
Does this dog like being handled and touched all over?*
If no, describe what happens:*
This field is hidden when viewing the form
Is your dog comfortable around people when being fed?*
If no, please describe their behaviour:*

Owner’s Assessment
Are there any behaviours you are concerned about with this dog?*
- Separation anxiety
- Resource guarding
- Dog aggression
- Human aggression
- Destructive behaviour
- Constant escaping
- Excessive barking
- Fearfulness, Stress/Anxiety
- None
- Other
If other, please describe:*
Are there any instances or situations where you would NOT recommend this dog to be rehomed?*
- Living with children?
- Living with elderly people?
- Living with another dog?
- Living with a cat?
- Living in a home without a secure yard?
- Living with livestock?
- Living with small animals?
- Living in a busy and highly stimulating home
Do you feel that this dog will cope being housed in a busy shelter environment, with a large number of dogs in close proximity, unfamiliar people, and exposure to noise and barking?*
With your knowledge of this dog, do you believe it is behaviourally sound, to not cause harm to other people, animals or itself and physically healthy enough to be rehomed to another person?*
Please share any other comments or information that would be useful for us or a new adopter to know:*

DECLARATION - Please select one option*
- As the sole legal and beneficial owner of the animal described above, I declare that: 1. I surrender as the sole legal and beneficial owner, the animal free of any third party; 2. I surrender all my rights, titles and interest in the animal to RSPCA NT and in doing so I understand that the animal will become the sole and absolute property of RSPCA NT; 3. I agree to indemnify RSPCA NT and keep RSPCA NT so indemnified against all claims (if any), costs and expenses whatsoever arising out of any action by any person claiming an interest in the animal.
- The animal is not owned by me, I am not aware of the animal’s true owner and I have made all reasonable efforts to identify the owner, therefore I believe the animal to be a stray.
- The animal has been abandoned by a third party on a property owned/controlled by me.
Please confirm both statements*
- I declare that all information provided in this application is true, accurate, and complete, and that I have not knowingly provided any false or misleading information.
- I am 18 years of age or older.
IMPORTANT INFORMATION - PLEASE READ CAREFULLY

By completing and signing this form, you are surrendering legal ownership of the animal described above to RSPCA NT. Once the animal is in care, RSPCA NT reserve the right to rehome the animal at their own discretion. You also acknowledge that you are not entitled to updates on the animal’s condition or whereabouts at any time.

A surrender fee applies. RSPCA NT will be in contact to discuss further if the application is approved for intake.
Owners name*
Date*
DD slash MM slash YYYY
Please upload a picture of your dog*
Accepted file types: jpg, gif, png, Max. file size: 40 MB.
CAPTCHA

Opening Hours

OPEN: 10:00 AM - 3:00 PM
Tuesday to Saturday
CLOSED: Sunday, Monday
& Public Holidays

Contact Us at reception@rspcant.org.au

80 Boulter Road,
Berrimah, Darwin NT
08 8984 3795

Facebook-f Linkedin Instagram

RSPCA National Lottery

Support RSPCA NT

Copyright 2024 © RSPCA Northern Territory | Privacy Policy

Website Design: Web365 Darwin *