Feline Relinquishment Form

Cat Information

Cat's Name*

First

Today's Date*

Cat's age*

Actual
Estimate

Gender*

Male
Female

Spayed/Neutered?*

Yes
No
Pregnant

If female, has she had a heat cycle?

Yes
No

If so, when was her last cycle?

If female, has she had kittens?

Yes
No

If so, how many litters?

Breed*

Mixed Breed
Purebred

Coloring*

Markings*

How long have you had your cat?*

Where or from whom did you obtain the cat?*

What are the specific reasons you need to surrender your cat?*

Behavior

Is your cat completely litter-box trained?*

Yes
No

If any litter-box issues, has your cat seen a vet?*

Yes
No

How often is the litter box scooped?*

How often is the litter box cleaned completely?*

What have you tried for the cat?*

Multiple Litter boxes
Covered litter boxes
Liners

What type of litter do you use?*

Clumping
Non-Clumping
Newspaper Pellets

Please select all the personality traits that fit your cat:*

Has this cat ever harmed a person?*

Yes
No

If yes, who was it & what was the situation?

You are obligated by law to inform us if this pet has bitten anyone in the past 10 days. Has this cat bitten anyone in the past 10 days?*

Yes
No

Did the bite break the skin?*

Yes
No

If yes, when did the bite occur, please describe the situation in detail: (If no just write n/a)*

This cat has lived with:*

Female cats
Male cats
Dogs
Livestock
Other
None of the above

This cat does well with:*

All cats
Male cats
Female cats
Dogs
Livestock
Other
None of the above

This cat does NOT do well with:*

All cats
Male cats
Female cats
Dogs
Livestock
Other
None of the above

Cat's favorite toys:

Describe your household*

Quiet/Calm
Active
Noisy

Where is the cat primarily kept?*

Indoor Only
Outdoor Only
Indoor/Outdoor

Is your cat declawed?*

Yes
No
Unknown

Would you describe your cat as a mouser?*

Yes
No
Unknown

Use the space below to tell us more about this animal - please be honest to help us find the best possible placement:*

Pet's Medical Information

When was the last time your cat was seen by a veterinarian?*

Current Veterinarian or Clinic:*

Does your cat require special handling at the vet? Describe:*

Does your cat have known health issues (allergies, seizures, etc) or any old injuries? Describe:*

What have you been doing to control the issues? Special diet, medication, other? Please Describe:

Is your cat on any type of medication currently? If yes please list mediation name(s), how much and how often.*

What Food does your cat eat?*

What happens if your cat's diet changes?*

Surrendering Party Information

Owner or Agent's Name (as it appears on driver license)*

First Last

Driver License Number*

Email*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home phone*

Alternate Phone

Upload Photo of your Drivers License or ID

Max. file size: 64 MB.

Consent*

By signing your name below, you give up all rights to the animal and surrender him/her to Ark-Valley Humane Society. Ark-Valley Humane Society is a minimal euthanasia facility, however we do euthanize animals when they do not fit our criteria for adoption. Our policies on euthanasia are aimed at protecting our staff, volunteers, potential owners, animals at the shelter, this animal, and the community at large. If you have specific questions about our policy, please ask an Ark-Valley Humane Society employee. Ark-Valley Humane Society is not obligated to disclose if an animal is euthanized, adopted, or transferred.

I certify that I own this animal or am acting as agent for the owner. If I am acting as agent for the owner, I certify that I have permission to surrender this animal and to relinquish all ownership rights of the animal on behalf of the owner. I certify that the said animal has not bitten anyone in the past 10 days. If the animal has bitten someone in the last 10 days, I am obligated to notify Ark-Valley Humane Society of the date and occurrence. I hereby relinquish all rights of ownership for this animal to the Ark-Valley Humane Society, Inc. and agree that the disposition of this animal be at the discretion of Ark-Valley Humane Society. I request that copies or summaries of the medical records for my pet be released to Ark-Valley Humane Society.

I agree to the following statement

Signature*

Date

CAPTCHA

719-395-2737

Owner Relinquishment Form - Feline

Cat Information

Behavior

Pet's Medical Information

Surrendering Party Information

719-395-2737

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