Soft Coated Wheaten Terrier Club of Greater Tampa Bay

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RSVP - Annual Meeting March 7th

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RSVP - Annual Meeting March 7th

I Need To Surrender

Do you have a Wheaten in Florida you are no longer able to care for? If you do, please complete the Behavioral/Medical Summary below.

Someone from our Rescue Committee will contact you quickly.

If you are in an urgent situation, please contact us.

I Need To Surrender Form

Why do you need to give up your Wheaten? Where did you get your Wheaten? Please be specific. Dog's Name*

Dog's Weight

Dog's Birthdate

Describe the dog's general condition. Is your dog house-trained? YesNo Is your dog microchipped? YesNo If yes, what brand of chip and what is the number? Vaccination Record - please fill in with the last date each vaccine was given.

Rabies

DHHLP

Kennel Cough

Other Vaccines What heartworm preventative do you use?

Date last tested for heartworms?

Date of last dose?

What flea treatment do you use? Date last dose was given? Is your dog spayed/neutered? YesNo If yes, when? Please describe any other surgeries your dog has had. Please indicate below if your dog is being or has been treated for problems with any of the areas listed: EarsEyesSkinTeethAllergiesNone of the abovePlease explain any 'yes' responses. Does your dog have any fears? If yes, please explain. Diet: Please fill in the information requested below regarding your dog's diet. Brand of food Amount fed How often Where do you feed your dog? Is your dog fed with other animals? YesNo If your dog overly protective of food? If yes, please explain. Any other general health comments? Behavior: The following questions are regarding your dog's behavior.Has your dog ever exhibited aggression towards any of the following? ChildrenMenWomenOther dogsOther animalsNone of the above If so, what type of aggression? BitingNippingGrowlingChasingJumpingOther Any other type of aggression? Training: Does your dog have any formal training? If yes, please explain. Have you ever used a bark or shock collar? YesNo Does your dog know how to? SitComeDownStayHeelShakeFetchSettleGet downLeave itNone of the above What word do you use for the following?

Crate

Potty

Outside

I'll be back

How does your dog walk on a leash? How does your dog respond to strangers? How does your dog behave in the car? How is your dog's behavior with other dogs? How is your dog around cats? How is your dog around children? How is your dog while bathing/grooming? How does your dog behave while at the vet? The following questions refer to your dog’s behavior in the house. What, if any, supervision does your dog need while in the house? Does your dog need to be crated while unattended? YesNo What chewing and/or destructive behaviors does your dog have? If your dog is male, does he mark in the house? YesNo Does your dog bark in the house? YesNo Does your dog take things off counters? YesNo Where does your dog sleep? Does your dog like to play with toys? YesNo The following questions refer to your dog’s behavior outside. Does you dog do any of the following activities? Fence jumpsClimbsBarksDigsChases other animalsPees/Poops in the yardPees/Poops on a leashNone of the abovePlease tell us other things we should know about your dog. Please provide the following information about your dog's caregivers.

Vet's Name

Vet's Phone

Groomer's Name

Groomer's Phone

Trainer's Name (if applicable)

Trainer's Phone

When we receive this form, one of our rescue coordinators will call you to talk about your dog. Please fill in the following information completely. Your Name* Address*

City*

State*

Zip Code*

Main Phone*

Alternate Phone

Email Address* Please provide a photo of your dog (max file size 5 MB).

Signature (type your name)

Date*

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The Soft Coated Wheaten Terrier Club of Greater Tampa Bay is registered as a charitable organization in Florida (Reg No. CH50498). A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL OR RECOMMENDATION BY THE STATE.