CRVA Dog Surrender Form
Please submit the form below only if you are located in VA (or OBX NC) and wish to surrender your Chesapeake Bay Retriever to rescue.
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Please enter your name & address:
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Please enter your phone numbers:
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Your chessie's name, age, sex and breeder's
information if available:
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Is your chessie purebred or mix? If mixed, with what?
pure
mixed
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Is your chessie spayed or neutered?
Yes
No
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Is your chessie up to date on all shots?
yes
no
rabies
7-way or similar
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Is your chessie heartworm negative and on
preventative?
tested negative
tested positive
not been tested
on preventative
not on preventative
being treated for heartworms
needs heartworm treatment due to being hw positive
I will treat for heartworms
I will not treat for heartworms
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When was the last time your chessie went to the vet?
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Vet's name, address, phone #'s and any other contact
information.
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I do hereby authorize my vet(s) to release all veterinary care information concerning my CBR to Chessie Rescue VA via phone, fax, letter, etc.
Yes
No
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Has your dog ever bitten? If so, explain:
no
yes
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Is your chessie housetrained?
yes
no
somewhat
Your chessie IS good with these other animals....
large male dogs
large female dogs
small male dogs
small female dogs
cats
other
Is your chessie definitely NOT good with any
particular animals?
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Please describe your dog, including any dominance
issues or likes and dislikes as thoroughly and accurately as possible.
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Is your Chessie used to being .....
inside
outside
both
and familiar with what type of fencing?
By what date do you need to surrender your chessie
to rescue?
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Please tell us why you need to surrender your
chessie to rescue.
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Will you travel to us to surrender your dog to rescue?
yes
no
part way
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Are you willing to make a donation to CRVA?
Yes
No
Please add any other information you feel would help
us better know your chessie.
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Your email address:
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Indicates Response Required
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