Mississippi Boston Terrier Rescue Owner Release Form
Boston Terrier Rescue of Mississippi offers a home, medical attention, and a caring environment
for unwanted, needy, and owner release Bostons until a suitable adoptive home can be found for
them. Mississippi Boston Terrier Rescue DOES NOT breed rescue dogs, sell rescue dogs for profit
or release a rescue dog for any form of research. Our goal and objective is to place rescue dogs in
loving, nurturing environments and enhance the love of the breed. Any actions contrary to those
stated above should be brought to the attention of the Mississippi Boston Terrier Board Members.
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Date: ______________Owner's Name:
___________________________________________________________
Owner's Address: ______________________ City: ________________ State: ___________ Zip Code: ________
Phone Number: ________________________
Dog's Name: ________________ Breed: Boston Terrier Is Dog Registered: _______________
If Dog is Registered, what is the dog's full registered name: ___________________________________
Spayed/Neutered? ___________ Gender: __________ Age: _________ Color: ____________
Is Dog House trained: Y/N Crate Trained: Y/N Leash Trained: Y/N Aggressive towards other dogs: Y/N
Obedience Trained: Y/N
Has he/she ever dug out, climbed, or jumped his fence: Y/N Is your dog on Heartworm Preventative: Y/N
What type of Monthly Heartworm Preventative do you use: ______________ What day of the month is his next treatment due:
_______________
Vaccination and Worming Records: (may opt. to attach Vet. Records if you wish)
Rabies: ____________ DHLPP: _______________ Bordetella: ______________
Has your dog ever been treated for other problems: Y/N If "Yes", please explain: _____________________
______________________________________________________________________________________________
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What type of dog food is your dog eating: _______________ __________ Is he on a Special Vet Prescribed Diet: _______
If "Yes", please list special dietary needs: _________________________________________________________
Vet's Name and Contact Information: ______________________________________________________________
Please Answer these questions which will help us to know your dog's likes/dislikes and how best to accommodate his needs
as well as any areas where he may need some additional training.
Does your Dog:
Sleep in Crate at Night: Y / N
Sleep on Bed or Furniture: Y / N
Do Tricks: Y / N
Get Along With Cats: Y / N
Get Along with Children: Y / N
Get Along with Other Dogs: Y / N
Like to Ride in Cars: Y / N
Knows Basic Commands such as "Sit", "Stay", "Come", etc: Y / N
Like to be Bathed/Groomed: Y / N
Like to Swim: Y / N
Come When Called: Y / N
House Trained: Y / N
Like to go for walks on Leash: Y / N
Please list any activities that your pet especially enjoys or anything that he particularly dislikes that you think may be pertinent:
__________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________.
Has your dog ever attacked or bitten another animal: Y / N If "Yes", please explain the circumstances:
________________________________________________________________________________
______________________________________________________________________________________________.
Has your dog ever attacked or bitten a person: Y / N If "Yes", please explain the circumstances: _______
______________________________________________________________________________________________
______________________________________________________________________________________________.
Please read, initial, sign, and date the following:
REPRESENTATIONS & WARRANTIES - We hereby represent and warrant to Mississippi Boston Terrier Rescue, their agents,
successors and assigns that the undersigned are the sole owner(s) of the above Boston Terrier. That I/we have full power and
authority to surrender this animal for adoption, that I/we are the only person(s) who are listed as registered owner(s) of this
animal with the AKC (if registered), that no other person or persons' signatures are required to effect a valid transfer of AKC
registration papers on this animal, and that no other person or persons have any legal or equitable ownership interest in this
animal._______(initial)
OTHER PERTINENT INFORMATION - We also agree to provide Mississippi Boston Terrier Rescue with any documents and all
other available information concerning this Boston Terrier which might assist in matching this Boston Terrier with the proper
prospective adoptive home, including health and shot records, pedigree, name and address of breeder or other person from
whom the dog was acquired, and information concerning this Boston Terrier's "dog history," such as important life events and
individual personality quirks. __________(initial)
SURRENDER OF RIGHTS - By executing this document, we understand that we are giving up forever all right, title and interest to
the above-mentioned Boston Terrier and we further understand that all future decisions regarding the placement of this animal
will be made solely by Mississippi Boston Terrier Rescue. We also understand that if this Boston Terrier is later found to have
such an unpredictable temperament as to be unsuitable for any placement, or if the animals quality of life is substantially
impaired, in the opinion of a competent veterinarian, by a chronic, irreversible, painful condition, euthanasia may be considered
as a final alternative to adoptive placement. __________(initial)
RELEASE AND INDEMNITY - I/we, the undersigned, hereby specifically and forever release, and hold Mississippi Boston Terrier
Rescue harmless, from any and all liability arising from the placement for adoption by Mississippi Boston Terrier Rescue of the
above-mentioned Boston Terrier, or for any other actions taken by Mississippi Boston Terrier Rescue in accordance with, and
in reliance on, the representations we have made, and the authorizations we have provided under the terms of this document.
We agree to indemnify and hold harmless Mississippi Boston Terrier Rescue for any damages suffered and expenses incurred
(including legal fees) in defending any legal action, whether for bodily injuries or death, property damage, breach of contract, or
otherwise, whether instituted by us or by any other person or persons including the adoptive owners, arising out of or in
consequence of the placement of the Boston Terrier, in reliance on the authorizations, representations and warranties we
have made in this agreement. __________(initial)
THIS IS A LEGALLY BINDING DOCUMENT FOR THE IRREVOCABLE SURRENDER OF YOUR BOSTON TERRIER FOR PLACEMENT TO
AN ADOPTIVE HOME. PLEASE READ CAREFULLY AND COMPLETELY BEFORE SIGNING. TAKE AS MUCH TIME AS YOU NEED TO
FULLY CONSIDER THIS IMPORTANT DECISION. IF YOU HAVE ANY QUESTIONS, PLEASE CALL: (601) 764-6848 or (601) 218-1137.
__________(initial)
I, _________________________________________, hereby make available for adoption, the dog, named
____________________________________, to Mississippi Boston Terrier Rescue. I certify that I am the owner of this dog,
free and clear of all other interests. I certify that this dog is not possessed of any dangerous or vicious propensities, and that I
have not willfully concealed information about the dog that might indicate such propensities. The information that I have
provided about this dog is true and complete. I hereby forever release, discharge, and agree to hold harmless and indemnify
Mississippi Boston Terrier Rescue, it's board of directors, it's members, 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 adoption or other
disposition of the above named dog. I acknowledge that this dog will become the property of Mississippi Boston Terrier
Rescue and that they may provide necessary medical treatments, surgeries, medications, etc. prior to placing the dog up for
adoption to a board approved, carefully screened home that best fits his/her needs and personality.
Owner's Signature: _________________________________________________ Date: ______________________
Print Name: _______________________________________________________
Address: _____________________________ City: _______________ State: _______ Zip Code: __________
Telephone: ___________________________ E-mail Address: ______________________________________