Intake Form

What is the Cat's Name & Date of Birth, if known?

How old is the cat?

What is the color of this cat?

Does the cat have short, medium or long hair?

How long have you had the cat?

Why are you surrendering this cat?

Is this an indoor or outdoor cat?

How does the cat act around children?

How does the cat act around other animals?

Who does the cat NOT get along with?

What kind of personality does the cat have (i.e. laid back, playful, dependent, shy)?

Does the cat have experience living with any of the following? Please mark all that apply.

Does the cat use a litter box?

I am able to offer a donation of at least $25.00 single cat/$50.00 family towards the support of this/these cats.

If you cannot offer a monetary donation, can you offer services as a volunteer?

Additional things we should know.

Veterinarian's Name:

Veterinarian's Phone Number:

Veterinarian's Address:

Date of the last vet visit:

My cats shots and preventative care are up to date.

My cat is spayed or neutered.

Has this cat had kittens?

Is this cat on any medication? If yes, what kind?

Does this cat have any medical conditions?

If yes please tell us about it.

I can provide medical records for my cat(s).

If yes, when & how many?

I represent and warrant that I am the lawful owner of the Animal(s), and I have full power and authority to surrender the Cat(s) to DCRSA. No other person has any legal or equitable ownership interest in the Cats(s).

I have disclosed to DCRSA all material information regarding the medical and behavioral history of the Cats(s). I willfully surrender all medical records and information pertaining to the Cats(s). DCRSA has my permission to contact my veterinarian for any necessary information pertaining to my Cats(s), and I hereby consent to the release of any and all medical information by any medical provider.

I further acknowledge that I am releasing the Cats(s) completely voluntarily and that no representations, considerations or promises of any kind have been made to me by DCRSA or any of its representatives.

I also hereby certify that the cat(s) has not bitten or scratched a human or another animal within the past 10 days.

I understand that by releasing the cat(s) to DCRSA, I relinquish all ownership or other interest in the cat(s) . I will not seek further information about the cat(s) and will not press DCRSA for details. My contact with the
cat(s) terminates at the time of surrender. DCRSA is under no obligation whatsoever to follow up with information about the cat(s).

I have fully read and understand this Surrender Agreement. I accept and agree to abide by its terms.

Authorized Owner or Legal Representative: I certify that I am over 18 years old and that I have the legal right to surrender this cat. I will assume full responsibility/liability for my actions.

I, (INSERT YOUR NAME ), an adult, do hereby voluntarily and irrevocably give, donate, surrender and release to Desert Cat Rescue & Sanctuary of Arizona, hereinafter referred to as DCRSA, the following animal(s), hereinafter referred to collectively as “Cat(s)/Kitten(s)”.