Surrender Application

Western Reserve Poodle Club Surrender Application

Unfortunately, we are unable to consider re-homing of surrendered dogs with serious medical conditions, due to the expense involved and due to the limited number of adopters available for these situations.

Also, no surrendered dog will be considered for placement until they are spayed or neutered.


Contact Information

Owner's Name

Your Email




City, State, Zip


Dog History

Dog's Name

 Standard (over 15 inches) Miniature (over 10 inches, under 15) Toy (under 10 inches)

Is your dog a purebred poodle?

Do you have AKC papers?

 Female Male

Spayed or neutered

Coat Color

NOTE: dogs must be spayed or neutered before an application for placement/re-homing can be accepted!



Where did you purchase or obtain your poodle?

If you got your dog from a breeder, have you contacted the breeder about returning her/him to the breeder? (Many breeders require this.)

Has your dog ever bitten anyone?

If so, what were the circumstances?

Does your dog have any behavioral problems (like aggression, separation anxiety, etc.)?

If so, what are they?

Does your dog have any serious health issues?

If so, what are they?

Reason for the need to re-home this dog

Personality and Behavior:

How would you describe the dog? (check all that apply)
 Friendly Playful Stubborn Needy Loving Calm Shy Aggressive Obedient

When outside, the dog uses
 Free Roaming Is Chained A Dog Pen Leash Invisible Fence Fenced Yard

Is your dog …

Friendly with other dogs?

Obedience trained?

Crate trained?


A barker?

Leash trained?

Good with cats?

Good with kids?

Medical History

Is the dog up-to-date with vaccinations?

Date of last vaccination

Has your dog been heartworm tested?

Date of last heartworm test

Does your dog currently take any medication?

If so, what conditions do they treat?

Does your dog have allergies?

If so, what type of allergy?

Does your dog have seizures?

If so, what is the frequency of the seizures?

Veterinarian Information

Name of Veterinarian



City, State, Zip

May we contact your veterinarian regarding the health history of your dog?

If so, please call your veterinarian and authorize her/him to release the history to us (Western Reserve Poodle Club) and inform them that we may be calling. Thank you.

Groomer Information

Do you have a regular groomer?

If so, please provide us with contact information for your groomer


Phone Number

Upon any surrendering situation, you will be required to sign a form entitled "Surrendered Dog Release of Liability", and an agreed upon donation to the poodle club rescue organization.