Full name of owner:

Name of dog(s):

Physical street address of owner:

City:

State:

Home telephone:

Work telephone:

Cellular telephone:

e-Mail Address:

Confirm e-Mail Address:

Time frame until release:
I can keep the Boston until a foster family is located—possibly several weeks.
I can keep the Boston for approximately one month.
I can keep the Boston for approximately three weeks.
I can keep the Boston for approximately two weeks.
I can keep the Boston for approximately one week.
I can only keep the Boston for the next few days .
The Boston needs to leave immediately.*

*Note: You may be asked to pay for boarding if the Boston needs to leave immediately.

Transportation:
I am willing to drive the Boston to Birmingham, Alabama.
I am willing to drive the Boston three hours to meet someone.
I am willing to drive the Boston two hours to meet someone.
I am willing to drive the Boston one hour to meet someone.
I am willing to drive the Boston thirty minutes to meet someone.
I cannot drive for any length of time.*

*Note: If a shelter volunteer cannot drive at all, you may be asked to find a driver to meet someone in the Birmingham area.

Time frame and transportation comments:

How much are you willing to contribute financially? I am not willing to contribute at all. $10.00 $25.00 $50.00 $75.00 $100.00 $150.00 $200.00 $250.00 $300.00 $350.00 $400.00 $450.00 $500.00 $750.00 $1,000.00
(Please consider a contribution. This will be used to cover food and medical care costs for the many Boston Terriers presently in foster care.)

I would like to make the above contribution with: Personal check at time of transfer Master Card Visa American Express Discover

If using a card, please provide card number, expiration date, and 3-digit code on back of card.
Card Number: - - - ; Expiration Date (mm/yy):

Information About Your Dog

Note: If you are releasing more than one dog, complete this form again for each dog. Click on the SUBMIT button below after completing form for each dog.

What is your dog's name?

Breed: Boston Boston Mix

If a mixed-breed, what percent Boston Terrier?
N/A Not even a drop of Boston Terrier Just a drop of Boston Terrier 25 percent 50 percent 75 percent 99 & 44/100 percent

If a mixed-breed, what is primary breed?
N/A Affenpinscher Afghan Hound Airedale Terrier Akbash Akita Alaskan Malamute American Bulldog American Eskimo Dog American Staffordshire Terrier American Water Spaniel Anatolian Shepherd Appenzell Mountain Dog Australian Cattle Dog/Blue Heeler Australian Kelpie Australian Shepherd Australian Terrier Basenji Basset Hound Beagle Bearded Collie Beauceron Bedlington Terrier Belgian Shepherd Sheepdog Belgian Shepherd Laekenois Belgian Shepherd Malinois Belgian Shepherd Tervuren Bernese Mountain Dog Bichon Frise Black and Tan Coonhound Black Labrador Retriever Black Mouth Cur Black Russian Terrier Bloodhound Blue Lacy Bluetick Coonhound Border Collie Border Terrier Borzoi Boston Terrier Bouvier des Flanders Boxer Boykin Spaniel Briard Brittany Spaniel Brussels Griffon Bull Terrier Bullmastiff Cairn Terrier Canaan Dog Cane Corso Mastiff Carolina Dog Catahoula Leopard Dog Cattle Dog Caucasian Sheepdog (Caucasian Ovtcharka) Cavalier King Charles Spaniel Chesapeake Bay Retriever Chihuahua Chinese Crested Dog Chinese Foo Dog Chinook Chocolate Labrador Retriever Chow Chow Cirneco dell'Etna Clumber Spaniel Cockapoo Cocker Spaniel Collie Coonhound Corgi Coton de Tulear Curly-Coated Retriever Dachshund Dalmatian Dandi Dinmont Terrier Doberman Pinscher Dogo Argentino Dogue de Bordeaux Dutch Shepherd English Bulldog English Cocker Spaniel English Coonhound English Pointer English Setter English Shepherd English Springer Spaniel English Toy Spaniel Entlebucher Eskimo Dog Feist Field Spaniel Fila Brasileiro Finnish Lapphund Finnish Spitz Flat-coated Retriever Fox Terrier Foxhound French Bulldog Galgo Spanish Greyhound German Pinscher German Shepherd Dog German Shorthaired Pointer German Spitz German Wirehaired Pointer Giant Schnauzer Glen of Imaal Terrier Golden Retriever Gordon Setter Great Dane Great Pyrenees Greater Swiss Mountain Dog Greyhound Harrier Havanese Hound Hovawart Husky Ibizan Hound Illyrian Sheepdog Irish Setter Irish Terrier Irish Water Spaniel Irish Wolfhound Italian Greyhound Italian Spinone Jack Russell Terrier Jack Russell Terrier (Parson Russell Terrier) Japanese Chin Jindo Kai Dog Karelian Bear Dog Keeshond Kerry Blue Terrier Kishu Klee Kai Komondor Kuvasz Kyi Leo Labrador Retriever Lakeland Terrier Lancashire Heeler Lancashire Heeler Leonberger Lhasa Apso Lowchen Maltese Manchester Terrier Maremma Sheepdog Mastiff McNab Miniature Pinscher Mountain Cur Mountain Dog Munsterlander Neapolitan Mastiff New Guinea Singing Dog Newfoundland Dog Norfolk Terrier Norwegian Buhund Norwegian Elkhound Norwegian Lundehund Norwich Terrier Nova Scotia Duck-Tolling Retriever Old English Sheepdog Otterhound Papillon Patterdale Terrier (Fell Terrier) Pekingese Peruvian Inca Orchid Petit Basset Griffon Vendeen Pharaoh Hound Pit Bull Terrier Plott Hound Podengo Portugueso Pointer Polish Lowland Sheepdog Pomeranian Poodle Portuguese Water Dog Presa Canario Pug Puli Pumi Rat Terrier Redbone Coonhound Retriever Rhodesian Ridgeback Rottweiler Saint Bernard St. Bernard Saluki Samoyed Schipperke Schnauzer Scottish Deerhound Scottish Terrier Scottie Sealyham Terrier Setter Shar Pei Sheep Dog Shepherd Shetland Sheepdog Sheltie Shiba Inu Shih Tzu Siberian Husky Silky Terrier Skye Terrier Sloughi Smooth Fox Terrier South Russian Ovtcharka Spaniel Spitz Staffordshire Bull Terrier Standard Poodle Sussex Spaniel Swedish Vallhund Terrier Thai Ridgeback Tibetan Mastiff Tibetan Spaniel Tibetan Terrier Tosa Inu Toy Fox Terrier Treeing Walker Coonhound Vizsla Weimaraner Welsh Corgi Welsh Springer Spaniel Welsh Terrier West Highland White Terrier Westie Wheaten Terrier Whippet White German Shepherd Wire-haired Pointing Griffon Wirehaired Terrier Xoloitzcuintle/Mexican Hairless Yellow Labrador Retriever Yorkshire Terrier Yorkie

If a mixed-breed, what is secondary breed?
N/A Affenpinscher Afghan Hound Airedale Terrier Akbash Akita Alaskan Malamute American Bulldog American Eskimo Dog American Staffordshire Terrier American Water Spaniel Anatolian Shepherd Appenzell Mountain Dog Australian Cattle Dog/Blue Heeler Australian Kelpie Australian Shepherd Australian Terrier Basenji Basset Hound Beagle Bearded Collie Beauceron Bedlington Terrier Belgian Shepherd Sheepdog Belgian Shepherd Laekenois Belgian Shepherd Malinois Belgian Shepherd Tervuren Bernese Mountain Dog Bichon Frise Black and Tan Coonhound Black Labrador Retriever Black Mouth Cur Black Russian Terrier Bloodhound Blue Lacy Bluetick Coonhound Border Collie Border Terrier Borzoi Boston Terrier Bouvier des Flanders Boxer Boykin Spaniel Briard Brittany Spaniel Brussels Griffon Bull Terrier Bullmastiff Cairn Terrier Canaan Dog Cane Corso Mastiff Carolina Dog Catahoula Leopard Dog Cattle Dog Caucasian Sheepdog (Caucasian Ovtcharka) Cavalier King Charles Spaniel Chesapeake Bay Retriever Chihuahua Chinese Crested Dog Chinese Foo Dog Chinook Chocolate Labrador Retriever Chow Chow Cirneco dell'Etna Clumber Spaniel Cockapoo Cocker Spaniel Collie Coonhound Corgi Coton de Tulear Curly-Coated Retriever Dachshund Dalmatian Dandi Dinmont Terrier Doberman Pinscher Dogo Argentino Dogue de Bordeaux Dutch Shepherd English Bulldog English Cocker Spaniel English Coonhound English Pointer English Setter English Shepherd English Springer Spaniel English Toy Spaniel Entlebucher Eskimo Dog Feist Field Spaniel Fila Brasileiro Finnish Lapphund Finnish Spitz Flat-coated Retriever Fox Terrier Foxhound French Bulldog Galgo Spanish Greyhound German Pinscher German Shepherd Dog German Shorthaired Pointer German Spitz German Wirehaired Pointer Giant Schnauzer Glen of Imaal Terrier Golden Retriever Gordon Setter Great Dane Great Pyrenees Greater Swiss Mountain Dog Greyhound Harrier Havanese Hound Hovawart Husky Ibizan Hound Illyrian Sheepdog Irish Setter Irish Terrier Irish Water Spaniel Irish Wolfhound Italian Greyhound Italian Spinone Jack Russell Terrier Jack Russell Terrier (Parson Russell Terrier) Japanese Chin Jindo Kai Dog Karelian Bear Dog Keeshond Kerry Blue Terrier Kishu Klee Kai Komondor Kuvasz Kyi Leo Labrador Retriever Lakeland Terrier Lancashire Heeler Lancashire Heeler Leonberger Lhasa Apso Lowchen Maltese Manchester Terrier Maremma Sheepdog Mastiff McNab Miniature Pinscher Mountain Cur Mountain Dog Munsterlander Neapolitan Mastiff New Guinea Singing Dog Newfoundland Dog Norfolk Terrier Norwegian Buhund Norwegian Elkhound Norwegian Lundehund Norwich Terrier Nova Scotia Duck-Tolling Retriever Old English Sheepdog Otterhound Papillon Patterdale Terrier (Fell Terrier) Pekingese Peruvian Inca Orchid Petit Basset Griffon Vendeen Pharaoh Hound Pit Bull Terrier Plott Hound Podengo Portugueso Pointer Polish Lowland Sheepdog Pomeranian Poodle Portuguese Water Dog Presa Canario Pug Puli Pumi Rat Terrier Redbone Coonhound Retriever Rhodesian Ridgeback Rottweiler Saint Bernard St. Bernard Saluki Samoyed Schipperke Schnauzer Scottish Deerhound Scottish Terrier Scottie Sealyham Terrier Setter Shar Pei Sheep Dog Shepherd Shetland Sheepdog Sheltie Shiba Inu Shih Tzu Siberian Husky Silky Terrier Skye Terrier Sloughi Smooth Fox Terrier South Russian Ovtcharka Spaniel Spitz Staffordshire Bull Terrier Standard Poodle Sussex Spaniel Swedish Vallhund Terrier Thai Ridgeback Tibetan Mastiff Tibetan Spaniel Tibetan Terrier Tosa Inu Toy Fox Terrier Treeing Walker Coonhound Vizsla Weimaraner Welsh Corgi Welsh Springer Spaniel Welsh Terrier West Highland White Terrier Westie Wheaten Terrier Whippet White German Shepherd Wire-haired Pointing Griffon Wirehaired Terrier Xoloitzcuintle/Mexican Hairless Yellow Labrador Retriever Yorkshire Terrier Yorkie

What is your dog's sex: Male Female

Is your dog spayed or neutered? Yes No

What is your dog's age?

What is your dog's date of birth? 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2007 2005 2006 2007 2008 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

What is your dog's color(s)?

What is your dog's weight?

What was your dog’s age when you acquired him/her?

Where and how did you acquire your dog?

If from a breeder, provide name of breeder.

If from a breeder, provide address of breeder.

Are AKC or CKC registration papers available?

Name of veterinarian:

Physical street address of veterinarian:

City of veterinarian:

State of veterinarian:

Zip code of veterinarian:

Phone number of veterinarian:

Has your dog had his vaccinations within the past year? Yes No

If yes, please provide dates of last vaccination series:

• Date of last DA2PL / CPV / CV vaccination series:
  (Canine Distemper Adenovirus type-2 Parainfluenza Leptospirosis / Canine Parvo Virus / Corona Virus):
  2008 2009 2010 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
  
  
• Date of last Rabies: 2008 2009 2010 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
  
  
• Date of last Bordetella: 2008 2009 2010 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Has your dog been tested for heart worms within the past six months? Yes No Not known

If yes, please provide date of last heart worm check and date of last heart worm preventative:

• Date of last heartworm check: 2008 2009 2010 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
  
  
• Outcome of heart worm check: Negative Positive Not known
  
  
• Date of last heartworm preventative: 2008 2009 2010 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

If your dog tests heartworm positive, what amount would you be willing to contribute toward the dog's heartworm treatment, which typically costs between $200 - $250 depending upon weight and overall health of the dog?
Nothing $25 $50 $75 $100 $125 $150 $175 $200 $225 $250 $275 $300 Full amount of treatment cost.

Has your dog ever been treated for ear infections? Yes No Not known

Does your dog have any skin problems?

Has your dog ever been treated for any other problems?

What brand of dog food do you feed your dog?

How many times is your dog fed daily?

At what times during the day is your dog fed?

How much is your dog fed?

Where does your dog sleep?

Where does your dog stay during the day?

Does your dog:

• Like to ride in cars? Yes No
• Like to swim? Yes No
• Jump fences? Yes No
• Dig? Yes No
• Let you take toys away from him/her? Yes No
• Chase cars? Yes No
• Urinate when scared? Yes No
• Come when called? Yes No
• Growl or lunge at strangers? Yes No

Is your dog:

• Good with children? Yes No
• Good with cats? Yes No
• Good with other dogs? Yes No
• Accustom to being groomed? Yes No
• Accustom to being walked? Yes No
• Crate trained? Yes No
• Obedience trained? Yes No
• Housebroken? Yes No

What commands does your dog know?

Has your dog ever growled at or bitten anyone? Yes No Not known

If yes, please explain the circumstances and outcome:

What does your dog like/dislike?

What are your dog’s best/worst points?

List any other information that might he helpful for placement or for the new owner:

Why are you giving up your dog?

Has the dog ever growled at or bitten you or anyone else since intake? Yes No Not known

I/We certify that we own the above dog and that this dog has not shown any signs of aggression or bitten anyone in the past ten (10) days and that the statements above are true and accurate. We agree to indemnify and hold harmless Birmingham Boston Terrier Rescue, Inc., and its members against all claims, suits, damages, liabilities, and costs related to or in any manner connected with this dog. We further acknowledge and understand that the dog becomes the property of Birmingham Boston Terrier Rescue, Inc., and that Birmingham Boston Terrier Rescue, Inc., may place and/or spay/neuter the dog as Birmingham Boston Terrier Rescue, Inc., sees fit.

Your submission of this Release Form is not a guarantee that Birmingham Boston Terrier Rescue, Inc., will accept the dog(s). Acceptance of your dog is solely at the discretion of Birmingham Boston Terrier Rescue, Inc.

PRIVACY POLICY: Information given to Birmingham Boston Terrier Rescue, Inc., is confidential and will not be shared with any individuals or organizations. Birmingham Boston Terrier Rescue, Inc., does not sell or rent the information you provide online to third parties.

I, , swear or affirm that all the information of this owner's release is true and correct. I further swear or affirm that nothing has been withheld that would adversely affect my surrender of the aforementioned Boston Terrier, or any other dog.

I, , authorize the above designated charge to the credit card selected. (Receipt will be mailed to address on file.)

Electronically signed by owner:

Electronically signed by co-owner:

Date Signed: 2008 2009 2010 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31