Surrender Request

Surrender Request Form

If you need to surrender a dog or cat to CHA Animal Shelter, please answer all questions in this form honestly and completely. A staff member will then reach out through email to discuss your animal(s) and see how and when CHA can best help you.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (This is the primary way we will contact you)*
example@example.com
Phone*
I need to surrender enter number* cat(s) AND/OR enter number* dog(s).
Reason for surrender (please be specific):*
I need to surrender a litter of 2 or more kittens (under 4 months of age) that DO NOT have a mother cat with them.*

YesNo

Number of kittens in the litter:
Estimated age and/or date of birth (if known)
Use the attached chart to estimate the ages of the kittens in your care:
Are the kittens spayed/neutered?

YesNoUnknownSome are spayed/neutered but not all
Please list the names and descriptions of each kitten:

Name:
Description:
Name:
Description:
Name:
Description:
Name:
Description:
Name:
Description:
Name:
Description:
Name:
Description:
Name:
Description:
Where did you get the kittens?
If strays, where and when found?
How long have you owned the kittens?

Provide more details about any incident where the kittens have aggressively bitten, scratched, or attacked humans:
Did the incident break the skin on a human?

YesNo
Date of incident:

If YES to any of the above, please describe more detail:
Did the incident break the skin on a human?

YesNo
Date of incident:

This animal is a:

DogCat

Are you in need of surrendering another animal?*

YesNoYes, a litter of 3 or more kittens (with or without a mother cat)

Provide information about the incident where the animal bit, scratched, or attacked:
Did the incident break skin on a human?

YesNo
Date of Incident

This animal is a:

DogCat

Do you have a third animal to surrender?

YesNo

Provide information about the incident where the animal bit, scratched, or attacked:
Did the incident break the skin on a human?

YesNo
When did the incident occur?

This animal is a:

DogCat

Do you have a fourth animal to surrender?

YesNo

Provide information about the incident where the animal bit, scratched, or attacked:
Did the incident break the skin on a human?

YesNo
When did the incident occur?

This animal is a:

DogCat

Surrender Contract

NOTE: You will be required to read and sign the below portion of the surrender form at the time of your surrender appointment. The wording of this section is included for your convenience.
Please accept my surrender fee of $40.00.

I'd like to donate an additional amount to help care for this animal $___.

Total I would like to donate today is $___.

I understand that if I am unable to pay the surrender fee, CHA Animal Shelter may not be able to take the pet(s) I have brought today.

___ By checking this box, I certify that I am financially unable to pay a surrender fee.

I hereby release, unconditionally, the animal described above, to CHA Animal Shelter. I understand that by relinquishing ownership rights of this animal, I will not be able to determine its final disposition. I understand that this animal will either be placed up for adoption or humanely euthanized.

___ By checking this box, I am stating that I want to be contacted in the event that my surrendered animal(s) cannot be placed on the adoption floor as I would like to redeem the animal(s). I understand that this does not guarantee I will be contacted.

I also understand that if I seek to reclaim this animal, I will go through the regular CHA Adoption procedures.

I also affirm that I have not taken this animal from another person without that person’s consent.
I understand that upon submission, this surrender request form will be sent to staff at CHA Animal Shelter. A staff member will then reach out to me via email within 1-3 business days to discuss scheduling an intake appointment for my animal(s).*

I understand
I understand that CHA requests a $40 surrender fee to help offset the costs of animal housing and medical care (such as spay/neuter surgery, vaccines, microchipping, etc.):*

I understand
I understand that I will be asked to fill out and sign the above surrender agreement at the time of my appointment.*

I understand
I understand that my animal(s) will be evaluated at the time of a scheduled intake appointment. If my animal(s) cannot be handled, demonstrate aggression or severe fear, or has other behavioral or medical concerns that CHA cannot manage then I will be asked to take the animal back with me as CHA will be unable to take in the animal(s).*

I understand
Should be Empty:

Surrender Request Form

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Animal Information

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Animal Information

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Animal Information

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Surrender Contract