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2. To help us place your dog in an environment best suited to his/her needs, please complete this questionnaire as completely and honestly as possible. Thank you!
4. Date
5. Animal #
6. Dog's Name
7. Kennel #
9. Gender

   1. Male

   1. Female

   1. Spayed

   1. Neutered
11. Breed
12. Please list any surgeries:
13. Please list any medical issues:
15. Date of last heartworm prevention:
    Date of last heartworm prevention:
16. Date of last flea/tick prevention:
    Date of last flea/tick prevention:
18. How long have you owned the dog?
19. Where did you get the dog?
21. When is the dog fed?

    1. A.M.
    2. P.M.
    3. Free feed
22. Brand of food:
23. Amount of food:
25. The dog is kept:

    1. Indoors
    2. Outdoors
    3. Both
26. When the dog is outside, it is kept:

    1. Tethered
    2. In fenced yard
    3. In outdoor kennel
    4. Other
27. Other:
29. Size and type of fence
30. Jumps fence

    1. Yes
    2. No
32. Has the dog had any obedience training?

    1. Yes
    2. No
33. Does the dog mind being picked up?

    1. Yes
    2. No
    3. Too big
34. Does the dog mind being held?

    1. Yes
    2. No
    3. Too big
36. Good with:

    1. Dogs
    2. Cats
    3. Kids
37. Kids ages:
39. Has the dog shown any aggression?

    1. Yes
    2. No
40. Explain.
42. Has the dog shown destructive behaviors?

    1. Yes
    2. No
43. Explain.
45. Reason for surrendering dog (please be honest)
47. Select all that apply to the dog.

    1. One person
    2. Shy
    3. Nervous

    1. Quiet
    2. Finicky
    3. Active

    1. Playful
    2. Outgoing
    3. Calm

    1. Demanding
    2. Noisy
49. Housebroken

    1. Yes
    2. No
    3. Partially
50. Good in car

    1. Yes
    2. No
    3. Uses carrier
51. Allowed on furniture

    1. Yes
    2. No
52. Jumps on furniture

    1. Yes
    2. No
54. Crate trained

    1. Yes
    2. No
55. Uses dog house

    1. Yes
    2. No
56. Digs in yard

    1. Yes
    2. No
57. Walks well on leash

    1. Yes
    2. No
59. Barks

    1. Yes
    2. No
60. If yes, explain.
62. Anything else potential adopters should know about the dog?
64. I hereby acknowledge that the information, which I have given to the County of St. Charles, is accurate and that the animal is released to the County of St. Charles for disposition and that said County is the rightful owner and I will make no claims whatsoever against the County. I understand and agree that the County of St. Charles is under no obligation to adopt this animal and that the County may otherwise dispose of this animal as it deems necessary.
66. First and Last Name
67. Date
    Date
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

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