Chesapeake Humane Society Form

Tell Us About Yourself
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Please provide a valid email address.*
If you do not have an email address, please use none@none.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code*
What is your preferred contact method? *

Tell Us About Your Pet(s)
Pet's Name*
Type*
Age*
Weight*
Gender*
Dog Breed
Cat Breed
Other Pet Species
How long have you owned this pet?
Medical Event
Has this pet had their rabies vaccination?

Yes (Rabies)No (Rabies)
Vaccine Name
Date of Vaccination
Please use XX/XX/XXXX format.
Where did they receive this vaccine?
What vet office does your pet use?
Put N/A if they do not have one.
What do you normally feed your pet?*
Please list your pet's current medications, illnesses, injuries, or ailments.
Has your pet ever bitten anyone?*

YesNo
Please give us a brief description of the bite incident.
Add a photo of your pet

Cancelof
Do you have a second pet?*

YesNo

Second Pet's Information
Second Pet's Name
Type
Age
Weight
Gender
Dog Breed
Cat Breed
Other Species
How long have you owned this pet?
Medical Event
Has this pet had their rabies vaccination?

Yes (Rabies)No (Rabies)
Vaccine Name
Date of Vaccination
Please use XX/XX/XXXX format.
Where did they receive this vaccine?
What vet office does your pet use?
Put N/A if they do not have one.
What do you normally feed your pet?*
Please list your pet's current medications, illnesses, injuries, or ailments.
Has your pet ever bitten anyone?*

YesNo
Please give us a brief description of the bite incident.
Add a photo of your pet

Cancelof
Do you have a third pet?*

YesNo

Third Pet's Information
Third Pet's Name
Type
Age
Weight
Gender
Dog Breed
Cat Breed
Other Pet Species
How long have you owned this pet?
Medical Event
Has this pet had their rabies vaccination?

Yes (Rabies)No (Rabies)
Vaccine Name
Date of Vaccination
Please use XX/XX/XXXX format.
Where did they receive this vaccine?
What vet office does your pet use?
Put N/A if they do not have one.
What do you normally feed your pet?*
Please list your pet's current medications, illnesses, injuries, or ailments.
Has your pet ever bitten anyone?*

YesNo
Please give us a brief description of the bite incident.
Add a photo of your pet

Cancelof
Do you have a fourth pet?*

YesNo

Fourth Pet's Information
Fourth Pet's Name
Type
Age
Weight
Gender
Dog Breed
Cat Breed
Other Pet Species
How long have you owned this pet?
Medical Event
Has this pet had their rabies vaccination?

Yes (Rabies)No (Rabies)
Vaccine Name
Date of Vaccination
Please use XX/XX/XXXX format.
Where did they receive this vaccine?
What vet office does your pet use?
Put N/A if they do not have one.
What do you normally feed your pet?*
Please list your pet's current medications, illnesses, injuries, or ailments.
Has your pet ever bitten anyone?*

YesNo
Please give us a brief description of the bite incident.
Add a photo of your pet

Cancelof
Do you have a fifth pet?*

YesNo

Fifth Pet's Information
Fifth Pet's Name
Type
Age
Weight
Gender
Dog Breed
Cat Breed
Other Pet Species
How long have you owned this pet?
Medical Event
Has this pet had their rabies vaccination?

Yes (Rabies)No (Rabies)
Vaccine Name
Date of Vaccination
Please use XX/XX/XXXX format.
Where did they receive this vaccine?
What vet office does your pet use?
Put N/A if they do not have one.
What do you normally feed your pet?*
Please list your pet's current medications, illnesses, injuries, or ailments.
Has your pet ever bitten anyone?*

YesNo
Please give us a brief description of the bite incident.
Add a photo of your pet

Cancelof

Final Information
If your animals are not spayed or neutered, are you willing to have them altered within 3 months of starting this program?*

YesNo
If your animals do not have their rabies vaccination, are you willing to get them vaccinated within 3 months of starting this program?*

YesNo
Please provide additional details on how we can assist you.
Important Details

By clicking "Submit" you understand and agree to the following:
- I understand that any pet(s) entering the Stronger Together program will be spayed/neutered if they are not already fixed.
- I understand that I must release my pet(s) to CHS to participate in this program. I understand that I will be able to adopt my pet(s) back at the end of the boarding period. The adoption fee for my pets will be waived, but boarding fees may apply. Applicable boarding fees will be discussed prior to pets entering the program.
- Communication is a vital part of the Stronger Together program. I understand that I, or a third-party representative, will need to check in with CHS once every two weeks while my pet(s) is in this program.
This application does not guarantee the placement of your pet(s) in this program. A CHS representative will reach out to the applicant within 2 business days.
If you have any issues or concerns with the information you've had to enter on this form please send us an email at outreach@chesapeakehumane.org.
How did you hear about the Chesapeake Humane Society?
Please verify that you are human*
Case Contact Plan:
Plan for continued assistance:
Org Notes 1
Medical:
Exams:
S/N:
Vaccines:
Microchip:
Bloodwork:
Flea Prevention:
HW Prevention:
Dewormer:
Snap test:
X-ray:
Other:
Org Notes 2
Medical: Exams: S/N: Vaccines: Microchip: Bloodwork: Flea Prevention: HW Prevention: Dewormer: Snap test: X-ray: Other:
Org Notes 3
Medical: Exams: S/N: Vaccines: Microchip: Bloodwork: Flea Prevention: HW Prevention: Dewormer: Snap test: X-ray: Other:
Org Notes 4
Medical: Exams: S/N: Vaccines: Microchip: Bloodwork: Flea Prevention: HW Prevention: Dewormer: Snap test: X-ray: Other:
Org Notes 5
Medical: Exams: S/N: Vaccines: Microchip: Bloodwork: Flea Prevention: HW Prevention: Dewormer: Snap test: X-ray: Other:
Should be Empty:

Tell Us About Yourself

Tell Us About Your Pet(s)

Second Pet's Information

Third Pet's Information

Fourth Pet's Information

Fifth Pet's Information

Demographic Information

Final Information