First Name *

Last Name *

Email *

Address *

City, State, Zip *

Nearest large city *

Home Phone

Other Phone

Other Phone Type Select Cell Work Other

Are you the owner of this dog? Yes No *

Does anyone else have an ownership interest in this dog? Yes No *

If yes, who?

Does the above grant their permission for you to relinquish this dog to SIRA for re-homing? Yes No

Dog's Name *

Gender Male Female *

Breed Select Shiba Inu Jindo Shiba Mix Jindo Mix Other *

If mix or other, please describe

Dog's age or DOB *

Color Select Red Sesame Black & Tan Cream Pinto Brindle Other *

Height at shoulder *

Weight *

Spayed/Neutered? Yes No *

Up to date on vaccinations? Yes No *

When was the last set of vaccinations given? *

If the dog is not UTD, what vaccinations are needed?

Date last flea/tick medication was given *

Date last heart worm medication was given *

Microchipped? Yes No *

If yes, what type? Avid Home Again Other

Microchip Number

Type of food *

Feeding frequency and amount *

Reason(s) you are looking to surrender your dog *

Have you attempted to surrender this dog to another rescue organization, shelter, or humane society before? Yes No *

If yes, please explain. Include the reason the dog was not accepted by the rescue organization, shelter, or humane society.

Check all obedience classes your dog has completed. Puppy Class
Beginning Obedience
Novice Obedience
Advanced Obedience
Agility
Canine Good Citizen
Behavior Modification
None
Other
*

If Behavior Modification or Other were selected, please describe.

Check all tricks and commands your dog knows. Sit
Down
Off
No
Heel
Leave it
Wait
Sit up
Shake
Roll over
Stay
Come
None
Other
*

How does your dog normally walk on leash? Select Heels Walks in front without pulling Pulls somewhat Pulls constantly Drags behind/Refuses to Walk *

How does your dog ride in a car? Select Sits/Lays down quietly Bounces around some Bounces around constantly Restrained with a harness Crated *

Has the dog escaped through doors/gates/fences? Yes No *

If yes, please explain

Where is your dog mainly kept? Indoors Outdoors *

Is your dog housebroken? Yes No *

Is your dog crate trained? Yes No *

Select all tendencies your dog has Select
Barking/Howling
Chewing
Digging
Marking
Jumping up on people
Jumping up on objects/furniture
Possessive of food
Possessive of toys
Mouthy when playing
Biting
Other
None
*

Has the dog ever bitten a human? Yes No *

If yes, please describe. Include dates, people involved, severity of bite, medical attention required and if bite was reported.

Has the dog ever injured/killed another animal (dog/cat/other)? Yes No *

If yes, please describe. Include dates, people/animals involved, severity of injury, medical attention required and if incident was reported.

Does your dog have any ongoing medical issues? Yes No *

If yes, please describe. Include any medications/treatments required and the future prognosis.

Does your dog have luxating patellas? Yes No *

If yes, what grade(s)?

Does your dog have any seasonal/food allergies? Yes No *

If yes, please describe

Other medical information

Please upload a few photos of your dog for our intake coordinator to verify that it is a Shiba or Shiba mix.

Photo 1 *

Photo 2

Photo 3

Photo 4

Photo 5

I acknowledge that I understand that if/when Shiba Inu Rescue Association takes my dog into their foster care program I will relinquish my rights as the dog's owner and have no further contact with or knowledge of of where the dog is placed.

*Constitutes electronic signature *