Surrender Form
Fill out this form to have your Shiba or Shiba mix considered for placement in SIRA's foster program.  The owner of the dog must fill out this form.
Tricks/Commands known.  Select all that apply:
Address:
Zip Code:
Nearest Large City:
First Name:
Other Phone:
Home Phone:
State:
City:
Email:
Last Name:
Dog's Name:
Gender:
Breed:
Yes
No
No
Yes
Yes
No
Avid
Home Again
Microchip Number:
If yes, what type?
Microchipped?
If no, what vaccinations are needed?
If yes, when were last vaccinations given?
Up to date on vaccinations?
Spayed/Neutered?
Weight:
Height:
Color:
Age or DOB:
If mix or other, please describe:
Date last flea/tick medication was given:
Date last heart worm medication was given:
Type of food:
Feeding frequency and amount:
Reason(s) you are looking to surrender your Shiba:
How does your dog get along with:
Women?
Children?
Veterinarian?
Dogs?  Specify gender/size/breed if appropriate:
Cats or other small pets?
Men?
How does your dog respond to:
Nail clipping?
Baths?
Brushing?
Loud noises?
How does your dog greet:
Visitors at the front door?
Visitors in the yard?
Strangers on the street?
Obedience classes dog has completed.  Check all that apply:
Puppy Class
Beginning Obedience
Novice Obedience
Advanced Obedience
Agility
Canine Good Citizen
Other
If other, please describe:
How does dog walk on leash?
How does dog ride in a car?
What type of fence is the dog usually contained in?
I do not have a fence
Yes
No
Indoors
Outdoors
Yes
No
Please select all tendencies your dog has:
Barking/Howling
Chewing
Digging
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)?
Yes
No
If yes, please describe:
Does your dog have any seasonal/food allergies?
Other medical information:
Sit
Down
Off
No
Heel
Leave it
Wait
Sit up
Shake
Roll over
Stay
Come
Yes
No
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.
Please upload a few photos of your dog for our intake coordinator to verify that it is a Shiba or Shiba mix
Owner Information
Has the dog escaped through doors/gates/fences?
If yes, please explain:
Dog is mainly kept:
Is the dog housebroken?
Is the dog crate trained?
Marking
Possesive of food/toys
Mouthy when playing
Biting
Jumping up on people/objects
Photos
Ownership Release
General Dog Information
Behavior
Training
Medical History
*Constitutes electronic signature