Middleburg Heights Animal Foundation

Feline Surrender Questionnaire

Today's Date:

Full Name:

Street Address:

City, State, Zip Code:

E-mail:

Phone Number:

Best Time to Call:

Cat's Name:

Breed:

Cat's Age:

Cat's Sex:

To enable us to find the best possible home for this cat, please fill in the information below as completely and accurately as possible.

Why are you giving up this cat?

How long have you owned this cat?

Where did you get this cat?

How many owners has this cat had?

What other types of pets did this cat live with?

Please describe any conflicts with this cat and the other pets:

List the ages of any children in the household:

Please describe any conflicts this cat had with the children:

Where did this cat spend most of its time?
  Indoors Only
  Mostly Inside
  In Garage
  Mostly Outside
  Always Outdoors

Where was the litter box kept?

How many cats shared this litter box?

How often does your cat urinate or defecate outside the litter box?

Please give an example.

How often do you change the litter?

Is your cat declawed?
  Yes
  No
If yes, why?

Does your cat use its claws on furniture or drapes?

Does your cat have a scratching post?
  Yes
  No
If yes, what type?
Where is it kept?

How often was this cat brushed or groomed?

Describe any problem with grooming:

How often does this cat get hairballs?

How often does this cat spray? When and where?

Have you ever consulted a trainer or behaviorist on any problem concerning this cat?
  Yes
  No

If yes, what kind of problems?

What form of discipline or correction do you use with this cat?

How does the cat react to discipline / correction?

Has this cat ever bitten or scratched anyone?
  Yes
  No
If yes, please describe:

Who is your dog's veterinarian or veterinary clinic?

What kind of health problems has this cat had?

Is this cat currently on any medications? If so please list them:

What type of flea control is your cat currently using?

Describe your cat's idea of a perfect day:

Check as many of the following that describe your cat's behavior:
Outgoing
Friendly
Affectionate
Independent
Relaxed
Playful
Slow to Adjust
Lap Cat
Shy
Talkative/Talks

It is understood that Middleburg Heights Animal Foundation does not buy or pay for dogs; but surrender donation is required to help cover medical care, housing, and feeding.

$25.00 for felines up-to-date with ALL vaccinations, rabies shot, and has been spayed or neutered. (Vet records required)
$50.00 for felines that need vaccinations and rabies shot; but has been spayed or neutered. (Vet records required)
$75.00 for felines up-to-date with vaccinations, rabies shot; but needs to be spayed or neutered. (Vet records required)
$100.00 for felines that need vaccinations, rabies shot, and to be spayed or neutered.

We also suggest that owners surrendering a cat donate the pet's carrier, litter box, food/water bowls, toys, grooming items, bags of the cat's food, copies of their medical records and anything else that the owner will no longer need due to the surrendering of the pet. This is a service to help place cats in new homes when their present owners can no longer keep them.

Please read and sign the following:

I, , hereby make available for adoption, the cat, named , to Middleburg Heights Animal Foundation. I certify that I am the owner of this cat, free and clear of all other interests. I certify that this cat is not possessed of any dangerous or vicious tendencies, and that I have not willfully concealed information about the cat that much indicate such tendencies. The information I have provided about this cat is true and complete. I hereby forever release, discharge, and agree to hold harmless and indemnify Middleburg Heights Animal Foundation, its Board of Directors, its members, officers, and agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above named cat. I further understand that in signing this agreement I surrender all rights to ownership of this pet immediately and permanently. I authorize any veterinarian this pet may have seen in its lifetime to release any and all medical records to MHAF.

Signature:       Date:

By typing your name in the signature box above you certify that the information included in this agreement is true and accurate to the best of your knowledge and that you are the individual requesting to surrender the above named pet to Middleburg Heights Animal Foundation and its foster homes.