Re-home Intake Form

We cannot consider re-homing a Senior Staffy unless this form has been accurately completed.

Red Star is a required field – if not completed the form cannot be sent.

How did you find out about our rescue? *

Date of first contact with us *

Day *

Month *

Year *

About You

Title and Full Name of Owner *

Street Address Line 1 *

Street Address Line 2

City/Town *

County *

Postal Code *

Telephone Number [Landline] *

If no landline write 'None'

Telephone Number [Mobile] *

If no mobile write 'None'

Email Address *

About the Dog to be Re-homed

Dog's Name *

Is the dog a full Staffy or a cross? *Full StaffyStaffy Cross

Sex of the dog *Dog {Male}Bitch (Female)

Please give the reason as to why you have to re-home the dog *

Age of the dog *

Show age in nearest whole year

Has the dog been sterilised? *No - entireYes - spayed/neutered

Is the dog up-to-date with vaccinations? *YesNoWe will ask for photo of vaccination card

Date of last vaccinations

Day

Month

Year

Date when Booster is due

Day

Month

Year

Has the dog ever been vaccinated against Kennel Cough? *YesNoDon't knowIf the answer is 'Yes' give date in following box

Date of Kennel Cough vaccination

Day

Month

Year

Dog's Micro-chip Number *

From 6 April 2016 all dogs must be micro-chipped by law

Is your dog micro-chipped to the same name and address as given on this form? *YesNo

If 'No' please give reason

If an entire bitch, when was she last in season?

Day

Month

Year

Has she ever had puppies?YesNo

If she has had puppies, please say when

Day

Month

Year

If an entire male dog, has he ever been used as a stud dog?YesNo

What is the dog's coat colour? *

Describe the coat condition *

About Your Dog - Behaviour and Needs

Is your dog good with children? *YesNo

If 'Yes' please give children's ages

If more the one child separate ages with a comma

Is your dog good with other dogs? *YesNoNot known

If 'Yes' is that only when out and about/or in the home?Out and AboutIn the HomeTick both boxes if they apply

If your dog has lived with other dogs please describe the circumstances along with breed, age and sex of the dog(s).

Is your dog good with cats? *YesNoNot Known

If 'Yes' has your dog lived with cats?YesNo

For how long has the dog lived with cats?

Please give period in years and months

Has the dog ever chased livestock (sheep/cows)? *YesNoNot Known

If 'Yes' whar happened?

Has the dog ever shown aggression? *YesNoNot Known

If 'Yes' what happened?

Has the dog ever bitten, snapped or snarled at anyone? *YesNoNot Known

If 'Yes' what happened?

Did the person bitten or other dog need treatment?YesNoNot KnownNot Applicable

Describe the treatment given and the severity of the bite

How does your dog react to strangers coming in to the home? *

Does your dog chew when left alone in the home? *YesNo

If left alone what does the dog do?

Is your dog used to travelling? *YesNo

If 'Yes' how does the dog normally travel?

Does your dog bark excessively? *YesNo

If 'Yes' when and what triggers his/her barking?

How long have you had the dog? *

Show in years and months

Where did you get the dog from? *

If you got the dog from a rescue, have you asked them to take him/her back?YesNo

If 'Yes' give details of their reply to you

Give the dogs daily feeding routine *Once Twice Three times or more

What do you feed the dog? *

If the dog has any food allergies please give details here

Is the dog used to bathing? *YesNoNot Known

Is the dog used to teeth brushing? *YesNoNot Known

Is the dog used to being kept indoors? *YesNo

Is the dog housetrained? *YesNo

If 'No" please give more details

Is the dog lead trained? *YesNo

Indicate what you use to walk the dog *Collar and leadHarness and lead

If your dog is NOT lead trained give full details

Has the dog ever attended classes? *YesNoNot Known

If 'Yes' gove details of classes attended

Has the dog has any medical problems in the past? Please give full details with dates if possible. *If no problems write 'None'

Name of dog's veterinary practice *

Street Address Line 1 *

Street Address Line 2

City/Town *

County *

Postal Code *

Telephone Number *

Is the dog a pedigree? *YesNo

Does your dog have any food or possession aggression?For example growls when anyone goes near his/her food bowl or toys. any bad habits

What else should we be made aware of about your dog that may give cause for concern in his/her new home

Please give as much further information about your dog which would be helpful to the new owners should we re-home him/her for you. Likes, dislikes, favouite toys, playfulness or otherwise, etc.

Where are you willing to transport to in order to get your dog to us? Our kennels are in the Stafford area or Worcester area - you will be advised which kennels to take your dog to nearer the time *

Is your dog registered with another rescue for re-homing? *If 'Yes' please give details including rescue's name and address. Otherwise write 'No"

If there is any more information concerning your dog that you feel we should be made aware of please give details

We must be told the truth about your dog because if at a later date we find out that information has been withheld, which leads to a dogs behaviour being totally unexpected in its new home, i.e. aggressive towards people/animals or he/she savagely attacks anyone, then we at Senior Staffy Club will not be held accountable. And if the new owners decide to prosecute, then this is a time we will give out information as to the whereabouts of previous owners.

By completing this form, I confirm that this is a true and accurate record of this dog and I wish to transfer ownership of my dog to Senior Staffy Club and for them to re-home him/her.

Owner's Name *

Date *

Day *

Month *

Year *

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