FELINE SURRENDER AGREEMENT THE FOLLOWING QUESTIONNAIRE PROVIDES US WITH INFORMATION ABOUT THE ANIMAL YOU ARE SURRENDERING. THIS INFORMATION WILL HELP US FIND THE MOST SUITABLE HOME FOR THE ANIMAL AND EFFECTIVELY COUNSEL THE NEW FAMILY. YOUR OPEN AND HONEST ANSWERS ARE VERY MUCH APPRECIATED. I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IS ACCURATE AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE, THAT I AM THE LEGAL OWNER OF THE ANIMAL(S), AND THAT THE ANIMAL(S) HAVE NOT BITTEN ANY PERSON DURING THE LAST 10 DAYS. I HEREBY RELEASE THE ANIMAL(S) INTO THE CUSTODY OF THE SAN ANTONIO HUMANE SOCIETY (SAHS). THE SAHS HAS MY PERMISSION TO USE ITS BEST JUDGEMENT IN THE PLACEMENT OF THE ANIMAL(S). I UNDERSTAND THAT ONCE THE SAHS TAKES CUSTODY OF THE ANIMAL(S) I WILL BE UNABLE TO RECLAIM OWNERSHIP OR ADOPT THE ANIMAL(S) UNLESS EXPRESSLY REQUESTED BY SAHS STAFF. I UNDERSTAND THAT ALTHOUGH THE SAHS STRIVES TO PLACE ALL ADOPTABLE ANIMAL(S) IN HOMES, ANY ANIMAL(S) DETERMINED TO BE UN-ADOPTABLE FOR ANY REASON MAY BE EUTHANIZED. THESE REASONS INCLUDE, BUT ARE NOT LIMITED TO, ILLNESS OR INJURY THAT THE SAHS IS UNABLE TO TREAT AND/OR TEMPERAMENT ISSUES THAT ARE BEYOND REHABILITATION. PRIOR TO EUTHANASIA THE SAHS CAN CONTACT YOU TO RECLAIM THE ANIMAL(S). PLEASE INDICATE BELOW IF YOU WISH TO BE CONTACTED. PLEASE CONTACT ME PRIOR TO EUTHANASIA PLEASE DO NOT CONTACT ME PRIOR TO EUTHANASIA NAME: ADDRESS: DATE: APT. NO.: CITY: STATE/ZIP: 1
PHONE NUMBER(S): SIGNATURE: BASIC INFORMATION CAT S NAME: BREED: ESTIMATED AGE: DATE OF BIRTH (IF KNOWN): / / SEX: MALE FEMALE SPAYED NEUTERED INTACT DECLAWED: FRONT BACK BOTH IS THIS CAT MICROCHIPPED? YES NO IS THE MICROCHIP REGISTERED TO YOU? YES NO GENERAL HISTORY 1. WHY ARE YOU SURRENDERING THIS CAT? 2. HOW LONG HAVE YOU OWNED THIS CAT? 3. INCLUDING YOURS, HOW MANY HOMES HAS THIS CAT HAD? 4. DID THIS CAT COME FROM ANOTHER RESCUE GROUP OR SHELTER? YES NO IF YES PLEASE NAME ORGANIZATION HERE: 2
PERSONALITY 1. DESCRIBE THIS CAT S ACTIVITY LEVEL: VERY ACTIVE MODERATELY ACTIVE COUCH POTATO 2. WOULD YOU DESCRIBE THE CAT AS LOUD OR TALKATIVE? YES NO 3. DOES THE CAT ENJOY BEING HELD? YES NO 4. PLEASE DESCRIBE THE CAT S LEVEL OF INDEPENDENCE ON THE SCALE BELOW: VERY SOCIAL 1 2 3 4 5 6 7 VERY INDEPENDENT 5. PLEASE DESCRIBE THE CAT S LEVEL OF AFFECTION ON THE SCALE BELOW: VERY AFFECTIONATE 1 2 3 4 5 6 7 NOT AFFECTIONATE 6. PLEASE DESCRIBE THE CAT S LEVEL OF FEARFULLNESS ON THE SCALE BELOW: FEARLESS 1 2 3 4 5 6 7 FEARFUL (SCARED OF EVERYTHING) 7. DOES THE CAT ENJOY PLAYING WITH TOYS? YES NO IF YES, WHAT TYPES OF TOYS? HISTORY WITH OTHER ANIMALS AND CHILDREN 1. HAS THIS CAT EVER LIVED WITH OTHER CATS? YES NO 2. IF YES, HOW WOULD YOU DESCRIBE THEIR INTERACTIONS? (CIRCLE ALL THAT APPLY) PEACEFULLY COEXISTED TOLERATED EACH OTHER CANNOT LIVE WITH OTHERS 3
3. HAS THIS CAT EVER LIVED WITH DOGS? YES NO 4. IF YES, HOW WOULD YOU DESCRIBE THEIR INTERACTIONS? (CIRCLE ALL THAT APPLY) AVOIDED EACH OTHER PEACFULLY COEXISTED CAT RAN FROM DOG 5. HAS THIS CAT EVER LIVED WITH CHILDREN? YES NO IF YES, WHAT AGES? 0-5 YEARS 6-12 YEARS 13-18 YEARS DIETARY HABITS (IT IS NOT UNCOMMON FOR CATS TO STOP EATING WHEN STRESSED. KNOWING WHAT FOOD AND TREATS THEY ENJOY IS VERY HELPFUL TO STAFF AND ADOPTERS) 1. WHAT BRAND OF CAT FOOD IS THIS CAT CURRENLTY EATING? 2. WHAT OTHER BRANDS HAS THIS CAT EATEN IN THE PAST? 3. DOES THE CAT EAT: DRY FOOD ONLY CANNED FOOD ONLY COMBINATION 4. HOW OFTEN DOES THE CAT EAT? FREE FED ONCE A DAY TWICE A DAY 5. WHAT TREATS DOES THE CAT ENJOY? MEDICAL HISTORY 1. DOES YOUR CAT HAVE A REGULAR VETERINARIAN? YES NO 4
NAME OF VET CLINIC: 2. DOES THIS CAT HAVE ANY UNUSUAL MEDICAL CONDITIONS? YES NO PLEASE EXPLAIN: 3. DOES THIS CAT REQUIRE ANY SPECIAL FOOD OR MEDICATIONS? YES NO PLEASE EXPLAIN: LITTERBOX HABITS 1. WHERE DOES THIS CAT NORMALLY LIVE? INDOOR OUTDOOR BOTH 2. DOES THE CAT HAVE ACCESSS TO A LITTER BOX IN THE HOUSE? YES NO 3. DOES THE CAT USE THE LITTERBOX? YES NO SOMETIMES 4. IF SOMETIMES, HOW OFTEN DOES THE CAT MAKE MISTAKES? 5. PLEASE DESCRIBE THE ACCIDENTS: URINATES OUTSIDE THE BOX URINATES ON CLOTHING/FURNITURE SPRAYS WALLS AND FURNITURE DEFECATES OUTSIDE THE BOX OTHER: 6. HOW OFTEN WAS THE LITTERBOX CLEANED? DAILY WEEKLY MONTHLY 7. DID THE MAJORITY OF THE ACCIDENTS OCCUR WHEN THE BOX WAS DIRTY? 8. WHERE IS THE LITTERBOX LOCATED? 9. WHAT TYPE(S) OF LITTER WAS USED? UNSCENTED SCENTED CLUMPING NON-CLUMPING CRYSTALS CLAY PINE PAPER 5
10. HOW MANY CATS SHARED A LITTERBOX? 11. HAS THERE BEEN A MAJOR LIFE CHANGE THAT COULD CAUSE THIS BEHAVIOR SUCH AS MOVING, A NEW BABY, A NEW PET, ETC.? YES NO 12. HAS THE CAT BEEN TO A VETERINARIAN TO RULE OUT UNDERLYING HEALTH ISSUES? IF SO, WHAT WAS THE CONCLUSION? PLEASE FEEL FREE TO TELL US ANY ADDITONAL INFORMATION YOU THINK WILL BE HELPFUL WHEN PLACING THIS CAT INTO A NEW HOME. 6