CAT/KITTEN SURRENDER PROFILE FORM Completed form must be submitted at scheduled surrender appointment. Contact Information (*Required): *Name of Person/Owner Surrendering *Phone Email *Street Address *City *State *Zip *Driver License # I understand there is a $40 surrender fee collected at the time of surrender. o Yes o No General History: Why are you surrendering this cat today? If we could help you resolve the issues surrounding the surrender of the cat would you be interested in keeping your animal? o Yes o No If yes, stop here and speak with a member of the Rescue Team for assistance. Cat s Name: Nickname: Age or approximate age: How old was this cat when you acquired him/her? Breed: Color: Is this cat a o Male o Female o Unsure Has this cat been spayed or neutered? o Yes o No o Unsure Has this cat been microchipped? o Yes o No o Unsure If so, chip # How long have you owned this cat? Including your home, how many homes has this cat had? Where did you acquire this cat? o Toledo Animal Rescue o Found as a stray o Born in my home o Friend/Relative o Pet store o Breeder o Free-to-good-home ad o Another shelter: What shelter? o Other Medical History: Did this cat receive annual exams by a veterinarian? o Yes o No o Unsure Name of Vet Clinic: Vet Phone: Name of Veterinarian: 1
I agree the Toledo Animal Rescue can contact the Veterinarian for current and past medical information regarding this animal. (Initial) Is this cat current on rabies vaccination? o Yes o No o Unsure Does this animal have any medical problems or previous injuries that require special attention or a special diet? o Yes o No o Unsure Explain: Please check all conditions that this cat has been diagnosed with or has been treated for: o Allergies o Urinary Tract Infection (UTI) o Feline Leukemia o Epilepsy/Seizures o Thyroid Disease o Skin Problems o Ringworm o Diabetes o Liver Disease o Kidney Disease o Heart murmur o FIV o Heart Worms o Obesity o Other: Dietary Habits: What brand of food did this cat eat? o Premium brand (Science Diet, Eukanuba) o Generic brand (Sam s brand, Dollar Store) o Grocery store brand (Purina, Old Roy) o Home cooked diet o Prescription Diet please describe: Which of the following does your cat eat? o Dry food only o Canned food only o Combination of dry and canned o Table scraps o Home cooked diet o Other Do you feed this cat treats? o Yes o No If yes, what kind? How often was this cat fed? o Once daily o Twice daily o Food always available o Other Litter Box Habits: Often a change in environment (family move, new pet, new baby, change of litter type) can cause a cat to use the litter box inconsistently. Please provide us with as much detail as possible regarding this cat s litter box habits. Sometimes litter box issues are the signs of health or behavioral problems (mild or serious) that may be modified or eliminated with treatment from your veterinarian. Did your cat have access to a litter box in the house? o Yes How Many? o No (skip to last question) Were there other animals in your home? o No Other cat(s) o Dog(s) o Small Mammals o Birds If other cats, how many cats shared a litter box? o One o Two o Three o Four or More Did this cat use the litter box? o Yes, consistently (Skip to the last question) o No o Sometimes---If sometimes, how often did the cat make a mistake? 2
When was the most recent litter box accident? o Within the last week o Within the last month o Six months ago o Six or more months ago o Has only happened a couple of times Please describe the accidents: o Urinates outside of the box on floor or flat surface o Urinates on clothing/furniture o Urine marks in the house (sprays walls) o Poops outside of the box All of the above Other If the cat urinates or poops outside of the box, does the cat most often go right beside the box? o No o Yes, please describe How often did you scoop the litter box? o Daily o Every few days o Weekly o Rarely What type of litter box was provided? o Covered o Uncovered o Automatic scooping What type of litter was used? (Check all that apply) o Scented o Unscented o Clumping o Non-clumping Crystals o Clay o Yesterday s News Pine Alfalfa Other If litter box issues were a problem, when did they begin? o Recently In the past month o In past six months o In the past year o Ongoing issues If you have multiple cats, have you witnessed this cat go outside of the box? o Yes o No Can you pinpoint an event (a move, new pet, change of litter style, new baby, traveling and not home much, etc.) that may have influenced/triggered poor litter box habits? Please describe what measures you have taken to attempt to correct this problem. Has this cat been examined by a veterinarian for his/her litter box issues to rule out any medical problems contributing to the cat not using the litter box? o Yes o No If yes, was a urine sample collected and examined by the vet? o Yes o No If yes, what was the diagnosis/outcome? 3
Personality Profile: What traits best describe this cat s personality (check all that apply): o Very energetic o Shy to strangers o Shy with some family members o Talkative o Playful o Friendly/affectionate to family members o Independent o Affectionate o Lap cat loves attention o Fearful o A loner o Stubborn o Goofball o Lazy Couch Potato o Other What s this cat s most favorite style of play (check all that apply)? o Very gentle o Enjoys playing hide-and-seek o Likes to play with other cats o Likes to play with dogs o Will learn tricks for treats o VERY energetic and rambunctious o Doesn t show a great interest in playing o Likes to play chase or pounce with certain toys o Other Lifestyle & Home Life Was this cat (check all that apply): o Indoors only o Outdoors only o Outdoors during the day, in at night o Indoors in cold weather o Indoor/Outdoor o In the garage or basement o Other: This cat sleeps (check all that apply): o Inside, on the floor o Inside, on a cat bed o Inside, on a chair or sofa o Inside, in bed with adults o Inside, in bed with children o In a crate o In a garage or barn o Outside, in a cat house o Outside, on ground or under porch If indoor only, does the cat try to escape? o Yes o No Did this cat have access to: o All areas of the home o Certain rooms only, which rooms Other If this cat has lived with other cats, how did they interact? (check all that apply) o Very affectionate o Playful and energetic o Groomed one another o Slept near one another o Peacefully coexisted o Ignored each other o Fought without injuries o Played too rough o Caused each other stress o Was picked on by other cat o Other If this cat lived with dogs, how did they interact? (check all that apply) o Adored each other o Avoided each other o Cat feared dog o Dog chased cat o Peacefully coexisted o Caused this cat stress o Played nicely with each other o Cat tormented dog o Slept near each other o Fought without injury 4 o Played too rough o Other
Has this cat regularly been around children? o Yes o No o Not Sure How old are the children? How does this cat interact with children? (check all that apply) o Ignored each other o Mutual affection o Cat and child played together o Child chased the cat o Cat was afraid of child o Child played too rough w/cat o Cat hissed at children o Cat swatted children o Cat bit children o Other This cat seems most comfortable with: o Women o Men o Children o Other animals o Senior citizens o Teenagers o Loves everyone! What is this cat afraid of? (check all that apply) o Thunderstorms o Loud Noises o Vacuums o Being Alone o Men o Women o Children o Strangers o Fast Movement o Car Rides o Restraint o Crates o Dogs o Cats o Vet Other If this cat has been aggressive towards people or animals, how would you describe the aggression? (check all that apply) o Yes, has attacked or bit people, animals, or both. o Yes, has hissed at or lunged at people, animals, or both. Please describe in detail any answers of yes: o No, has shown no aggression towards animals or people and I certify that, to the best of my knowledge, this animal has not bitten any person or animal, nor has it shown signs of aggression to any person or animal. (Initial) Does this cat have any areas of sensitivity where he/she does not like to be touched? o No o Yes, Please describe areas and reaction: 5
Please feel free to add additional comments that you think would be helpful to the Rescue Team staff, potential adopters, or a future owner. RELINQUISHMENT OF OWNERSHIP AND GENERAL RELEASE OF ALL CLAIMS My signature below certifies that I am the owner of, or have legal authority to surrender, the animal described above to the Toledo Animal Rescue. I certify that I have disclosed all information about the animal concerning health, behavior, history, and that all of the above statements and information are true and correct. I hereby relinquish and surrender all rights and ownership of the animal, and any right to information regarding the animal. I understand that Toledo Animal Rescue cannot guarantee that the animal will be placed for adoption. Signature Date I hereby agree and understand that I have voluntarily relinquished all ownership and rights to the animal, and that Toledo Animal Rescue has the sole and exclusive right to make all decisions and take all actions related to the animal. I further agree to forever discharge and release Toledo Animal Rescue from all claims, liability, and damages related to the animal in any way. Signature Date 6