Surrender Form | CSRA 2024

Cocker Surrender Form

COCKER SPANIEL RESCUE AUSTRALIA

(under the umbrella of English Cocker Spaniels Australia Incorporated) ABN: 57 202 992 447,

Registered Charity with the ACNC, CCP 3163 Postal Address:: PO Box 293 GLENSIDE SA 5065 www.csra.org.au https://www.facebook.com/CockerSpanielRescueAustralia/

Please provide answers to all questions, failure to do so may result in your form being rejected.

All questions must be answered truthfully.

We are not a shelter, we do not have kennels/runs. We are a foster based rescue group. Dogs are kept in carers homes. All our foster carers are volunteers, and their safety is paramount to us.

We will not risk harm to our foster carers, their family members or their pets.

The receipt of your Surrender Form will be acknowledged via text & email.

Please ensure that you check your Spam/Junk folder

Cocker Spaniel Rescue Australia (under the umbrella of English Cocker Spaniels Australia Inc) reserves the right to refuse any application without prejudice or explanation.

Please note, all applicants must be over the age of 18 years

I confirm that I am over the age of 18 years

Signed (releasing owner’s name printed):

THIS FORM CONSTITUTES A LEGAL AGREEMENT:

Surrendering Owners Declaration:

I declare that I am the owner of the Cocker Spaniel referred to herein. I declare that all information provided by me is true and correct. I understand that there are severe penalties for rehoming aggressive dogs. I hereby surrender my Cocker Spaniel into the care of Cocker Spaniel Rescue Australia (under the umbrella of English Cocker Spaniel Australia Inc). I understand that upon signing the declaration, that I relinquish ownership of, and any and all interest in the Cocker Spaniel referred to herein. I also understand that Cocker Spaniel Rescue Australia (under the umbrella of English Cocker Spaniel Australia Inc) may not be able to accept my dog for rehoming.

IS THE DOG REGISTERED IN YOUR NAME?

YES

If yes, please provide a copy of the current registration document and continue with this form. If you have answered no, unfortunately only the registered owner can surrender the dog.

SURNAME:

GIVEN NAME:

PERSONAL DETAILS

STREET ADDRESS:

SUBURB:

HOME TELEPHONE NUMBER:

STATE:

POSTCODE:

MOBILE TELEPHONE NUMBER

EMAIL:

DETAILS OF THE DOG YOU ARE SURRENDERING:

Name of the dog:

Breed:

Date of Birth (age):

Colour/Markings:

Microchip number:

Sex of Dog:

Male

Female

PLEASE NOTE: If your dog is yet to be desexed, and if you have the financial ability to do so, could we ask you to please arrange to have the dog desexed asap. This will assist us financially if you’re able to do so. However, if you’re unable to proceed with the desexing, this will not prevent you from surrendering the dog, we will arrange for the desexing to be done once the dog has settled into care.

Is the dog desexed? Required

Yes

If no, would you be in a position to have the dog desexed prior to being surrendered? Required

Yes

Has the dog been vaccinated: Required

Yes

If yes, please provide the date and details of last vaccination (i.e. C3, C4, C5 etc)

If no, would you be in a position to have the dog vaccinated prior to being surrendered? Required

Yes

Has the dog ever been used for breeding: Required

Yes

If yes (female), how many litters has the dog had?

If yes (male), how many litters has the dog had?

Does the dog have behavioural issues? Required

Yes

If yes, please provide details of the behavioural issues. There are severe penalties around the rehoming of aggressive dogs.

Does the dog have separation anxiety?: Required

Yes

If yes, could you please advise what training has been undertaken and by whom? If there are reports prepared by a professional trainer, could you attach the report to this application.

Has the dog bitten anyone?: Required

Yes

If you have answered Yes, please advise exactly what happened in the lead up to the incident.

Has the dog shown any aggression?: Required

Yes

If you have answered Yes, please advise exactly what prompted the dog to show aggression.

ADDITIONAL INFORMATION
Please answer the following questions truthfully, as we need this information to be able to place the dog with the best possible foster carer and then ultimately an adopter. We match the needs of the dog with the foster carer/adopter, not the other way around, the dog comes first. We do not want our foster carers and their family members placed in any danger. We also need to be aware if the dog has a serious medical issue, hence we need truthful answers. We cannot proceed with the surrender unless we receive full veterinary records for the dog in the first instance.

What is the primary reason for the dog being surrendered (i.e. behavioural problems, economic reasons, housing reasons, time-poor, council/shire directive etc)?

How is the dog with children under 5 years of age (i.e. do they growl, run at them, jump on them, bark at them, round them up, or is perfectly fine, ignores them)?

How is the dog with other dogs (i.e. do they growl, run at them, bark at them, or ignores them, gets on with other dogs etc)?

How is the dog with cats (i.e. unknown, ignores them, growls at them etc)?

How is the dog in the car (i.e. do they enjoy going for car rides, or absolutely hate them)?

What items, if any, will be coming with the dog (i.e. bed, toys, special bowl, collar/lead, food, nothing)?

What food does the dog currently eat (this can include treats, how many meals do they have per day)? Will you be sending any food with the dog?

Is the dog used to being home alone during the working day or have they always had someone with them?

Would you describe the dog as placid or boisterous (i.e. happy to do their own thing, or needs mental and physical stimulation constantly?

Is the dog a ‘jumper’ i.e. able to jump fences/gates? If so, what height of fence/gate can the dog jump over?

Does the dog have any illnesses, allergies or growths etc? If so, please provide details (including any medications they have been prescribed)

What Veterinary Clinic does the dog attend? (please supply name, address and telephone number)

Will you be advising your Veterinary Clinic regarding the dog? By you advising them, and giving your permission, it will make it a little easier for veterinary clinics to obtain their records in the future. You can do this when you request a complete copy of her records to be sent to CSRA (davina@csra.org.au)

Who was the breeder of the dog? Please supply the Certificate of Pedigree, or any other paperwork provided by the Breeder (seller).

Is there any other information you would like to provide us with?

It would be appreciated if you could include a photograph (or two) of the dog, please.

Cocker Spaniel Rescue Australia (under the umbrella of English Cocker Spaniels Australia Inc) reserves the right to refuse any application without prejudice or explanation.

DOCUMENTS TO BE ATTACHED WITH THE SURRENDER FORM:

Copy of Dog Registration Certificate

Copy of Veterinarian Clinical Records

Copy of Notes from Behavioural Specialists

Copy of Certificate of Sterilisation

Copy of Certificate of Vaccination

Copy of Certificate of Pedigree (or paperwork provided by the Breeder/Seller)

Photos

Copy of Dog Registration Certificate

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