I, _______________________________, an adult, do hereby voluntarily and irrevocably give, donate,
surrender and release to Cherished Cockers, hereinafter referred to as CC, the following
animal(s) hereinafter referred to collectively as "Animal(s)":
Animal(s) Name(s):_____________________________________________________________________________
Male_______ Female________ (if multiples, list numbers)
Color(s):__________________________________________________________________
Age(s):_________________________________________
I represent and warrant that I am the lawful owner of the Animal(s), and I have full
power and authority to surrender the Animal(s) to CC. No other person has any legal or
equitable ownership interest in the Animal(s).
I have disclosed to CC all material information regarding the medical and behavioral history
of the Animal(s). I willfully surrender all medical records and information pertaining to the
Animal(s). CC has my permission to contact my veterinarian for any necessary information
pertaining to my Animal(s), and I hereby consent to the release of any and all medical
information by any medical provider.
Veterinarian's name:_________________________________________________________
Address:__________________________________________________________________
City, State zip: _____________________________________________________________
Telephone Number_________________________________________________
I further acknowledge that I am releasing the Animal(s) completely and voluntarily and
that no representations, considerations or promises of any kind have been made to me by
CC or any of its representatives.
List any particular concerns or things CC should know about the Animal(s) - good and not so
good:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________
I understand that by releasing the Animal(s) to CC, I relinquish all ownership or other
interest in the Animal(s). I will not seek further information about the Animal(s) and
will not press CC for details. My contact with the Animal(s) terminates at the time of
surrender. CC is under no obligation whatsoever to follow up with information about the
Animal(s).
I hereby release and forever discharge CC from any and all rights, claims, obligations,
liabilities and causes of action whatsoever arising out of relating to the ownership,
possession, or disposition of the Animal(s), and I agree to indemnify and hold harmless
CC from and against any and all such rights, claims, obligations, liabilities, and causes
of action which may be asserted by third parties.
This is a legally binding document for the irrevocable surrender of your Animal(s) to CC.
I have fully read and understand this Surrender Agreement. I accept and agree to abide by
its terms.
DATE:________________________________________________
OWNER'S SIGNATURE:____________________________________________________
OWNER'S NAME: _________________________________________________________
OWNER'S ADDRESS:_______________________________________________________
City, State zip __________________________________________________________________
OWNER'S TELEPHONE NUMBER(S)__________________________________________
OWNER'S EMAIL ADDRESS:_________________________________________________
WITNESS:_____________________________________________________________________
CC AGENT TAKING CUSTODY:__________________________________________________
Cherished Cockers
C/O Christine Bacon
8216 Rushton Drive
Mentor, Ohio 44060-2025