Step 1 of 7 - Section 1 - About You 0% The Surrender Intake form is separated into 7 stages. Each stage will be verified for required answers before proceeding to the next section. Your dog will be placed much sooner if you can supply photograph(s). Total size must be less than 1 Mb per picture and the picture format must be jpeg (.jpg). Please, no humans in the photographs! If you do not know the answer to a question, just answer N/A. If multiple choice questions don't show the answer you want, you can enter further explanation in the 'Additional Comments' at the end of the form.Your Full Name:* First Last Do you have an email address:* Yes No Email:* Enter Email Confirm Email Primary Phone:* Enter only numbers - e.g. 555 555 5555.Cell Phone: Enter only numbers - e.g. 555 555 5555.Business Phone: Enter only numbers - e.g. 555 555 5555.Street Address:* City:* Province:*ONQCSelect your ProvincePostal Code:* Closest major City: Answer this if you live in a rural community.How did you hear about Danes in Distress:Used PreviouslyVeterinarianAnimal ShelterFriend / Associate 2 - About the Great Dane you are surrenderingDane Name:* Age - Years:*Please enter a number from 0 to 15.If less than 1 y-o, enter 0 and then the number of months below.Age - Months:*Please enter a number from 0 to 12.Date of Birth (if known): Day Month Year Colour:*BlackBlueMantleBrindleFawnHarlequinMerle or MerlequinWhiteSelect the colour which closest matches.Gender:* Male Female Neutered / Spayed:* Yes No Month of last Season:Not ApplicableJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWhat Year:* Enter as YYYY - e.g. 2010Are its ears cropped: No Yes Weight: Specify lbs or kg.Height: Microchip or Tattoo Number: Reason for Surrender:* How long have you had the Dane:* Where did you get the Dane:* Breeder Friend Internet Is the Dane CKC registered:* No Yes Will you sign over registration:* No Yes Registration papers are NOT given to Adopters, but retained on file by DiD.Is this Dane a house pet:* No Yes Is this Dane housetrained:* No Yes Is this Dane leash-trained:* No Yes Has it had Obedience Training:* No Yes Do you ever walk it off-leash:* No Yes Does it stay with you:* No Yes Is it crate trained:* No Yes Reaction to being crated:* Reaction to other dogs:* Reaction to Cats:* Has it been exposed to livestock: No Yes Reaction to Children:* Reaction to Strangers:* Has it ever bitten or shown aggression towards a person:* No Yes Detail the circumstances and any injuries sustained:* What is its General Temperament:* Examples: Happy-go-lucky, fearful, timid, playful, etc.What is its Health status/general condition:* Any Major Health issues or illnesses:* No Yes Is the Dane Deaf:* No Yes Is the Dane Blind:* No Yes Specify these:*Specify any current medical conditions requiring treatment:*Has the Dane ever been vaccinated:* No Yes Has the Dane ever received a Rabies vaccine: No Yes Date of last Rabies Vaccination: Day Month Year Has the Dane ever received a DA2PPV vaccine: No Yes This vaccine is commonly known as Distemper vaccineDate of last DA2PPV Vaccination: Day Month Year Please itemize any other vaccines previously given: Other vaccines may include Bordetella, Lyme, etc.Has the Dane ever had Heartworm medication: No Yes Don't know Specify Brand used:* What Year was the Test done:* Vet Clinic used for the Dane:* If no vet, enter N/AVet - Street Address:* Vet - City:* Vet - Phone:* How long has the Dane been left alone:* Where is the Dane kept when no one is home:* Specify any behavioral issues:*e.g. chewing, digging, barking, jumping, etc.The Dane LIKES the following:e.g. Car rides, walksThe Dane DISLIKES the following:e.g. nail clipping, baths, etc.Has it been boarded at a kennel or elsewhere: No Yes How did it react: What food brand is the Dane currently being fed:* How often is it fed daily:* How much per meal: At what time(s) do you feed: Specify any special feeding instructions: Are you willing to keep the Dane until a suitable Adopter is found:* No Yes Can you keep the Dane at your home until it is altered:* No Yes If we can place your Dane, will you make a donation to cover expenses:* No Yes Additional Comments:Do you certify that the answers given are true:* No Yes If there are Public Health issues (e.g. human aggression, rabies infection) not disclosed, you could be liable for civil action against you!Click on the Choose File buttons below and select the photograph filename on your hard drive Photograph size must be less than 1 Mb per picture and picture format must be .jpg. Upload Picture 1Accepted file types: jpg, Max. file size: 256 MB.Upload Picture 2Accepted file types: jpg, Max. file size: 256 MB.Upload Picture 3Accepted file types: jpg, Max. file size: 256 MB.