Boston Terrier Rescue of North Texas

Description of Boston Terrier:

1. Animal Name: 

2. Gender:  Male  Female

3. Neutered/Spayed:  Yes  No

4. Weight: 

5. Age or DOB: 

6. Housetrained:  Yes  No

7. Color: 

8. Reason for Surrender:

9. Current Medicines: 

10. Why? 

11. Is this dog a house dog:  Yes  No

12. Can this dog be trusted stay in the house uncrated
when no one is home?:  Yes  No

Does the dog like:

13. Adults:  Yes  No

14. Children:  Yes  No

15. Cats:  Yes  No

16. Other Dogs:  Yes  No

17. Has your dog ever attacked another animal?  Yes  No

18. Attempted to bite an animal?  Yes  No

19. Dog aggressive?  Yes  No

20. Cat aggressive?  Yes  No

21. Has this dog ever bitten another dog?  Yes  No

22. A human being?  Yes  No

23. Attempted to bite a human being?  Yes  No

Does the dog do any of the following:

24. Sleep in bed with a person:  Yes  No

25. Destroy/chew furniture:  Yes  No

26. Dump trash:  Yes  No

27. Chew:  Yes  No

28. Excessively Bark/Howl/Whine/Talk:  Yes  No

29. Growl at strangers:  Yes  No

30. Ride well in car:  Yes  No

31. Crate Trained:  Yes  No

How would you describe this dog:

32. Shy  Friendly  Noisy  Quiet  Gentle  Active  Protective  Friendly  Playful  Submissive  Dominant  Aggressive to People  Aggressive/Possessive of Toys 
Aggressive/Possessive of Food

33. Have you been the continuous owner of this dog?   Yes  No

34. Last visit to the vet? 

35. Is this dog up to date on vaccinations?  Yes  No

36. Is this dog spayed or neutered?  Yes  No

37. Has this dog been on heartworm preventative?  Yes  No

38. What kind? 

39. Date of last pill? 

40. Medical records available:  Yes  No
(please provide a copy of all medical records if available)

41. Any special health or physical problems? 

42. Vet’s name: 

43. Address: 

44. Phone number: 

I, "signature below", release and surrender of my free will the following described Boston Terrier, and hereby make available for adoption or any other disposition of the animal named "below", to Boston Terrier Rescue of North Texas, Inc.

I certify that I am the owner of this animal, free and clear of all other interests. I certify that this animal is not possessed of any dangerous or vicious propensities. The information I have provided about this animal is true and complete to the best of my knowledge. I, hereby and forever release, discharge and agree to hold harmless and indemnify The Boston Terrier Rescue of North Texas, its Board of Directors, Officers and Agents from all claims, demands, actions, causes of action or liability of any kind whatsoever arising as a result of or in connection with the adoption or any disposition of the above name animal. I understand that the BTRNT, Inc. Rescue shall not be held liable in any manner for their actions in the disposition of the above described animal, and that I relinquish all claims to the above described animal.

I understand that Boston Terrier Rescue of North Texas provides a service to help place a Pet in a new home when the present owner can no longer keep the animal for whatever reason. This service is free; however a donation to help pay for vetting and other expenses is always appreciated. In order to help defray any expenses incurred by the BTRNT, Inc., a non-profit organization, for the animal and to help in their efforts to rescue other Boston Terriers, I would like to make a donation in the amount listed below. (Your generosity is greatly needed and appreciated.)

I also agree my name and phone number may be released to the new owner of this animal and that the new owner may contact me if she/he wishes to gain further information about this animal.

45. Signature (Owner's Name): 

46. Date: 

47. Email: 

48. Phone: 

49. Adress: 

50. City, State, Zip Code: