Feline: Owner Surrender Request

Survey Request Information

Date Survey Completed*

Why do you want to surrender this cat?*

Where did you receive this cat from?*

Please provide your full name and phone number so a member of HSHA can contact you regarding this surrender.*

Please provide the name and location of the animal shelter*

Please provide the name and location of the animal rescue*

Please explain "other"*

Residing County of Owner*

Dauphin County
Cumberland County
Perry County
Other

What county?*

Cat Information

Cat's Name*

Cat's Breed and/or Colors*

Cat's Age*

Gender*

Is the cat declawed?

Yes, all four paws
Yes, front paws only
Yes, back paws only
No
Unknown / no sure

Length of Time Owned*

Owner Information

Name*

First Last

Phone*

Email*

Secondary Contact Information

Veterinary & Medical Information

Please be prepared to provide accurate up-to-date information of medical history if approved for surrendering.

Name of Veterinarian

Date of Last Veterinarian Visit

Vaccinations*

Up-to-Date
Not Up-to-Date
Never Received
Unsure

Known Medical Conditions*

Any current medications?*

Yes
No
Unknown

Has the cat ever been injured?*

Yes
No
Unknown / Not sure

Behavioral Assessment

Has the cat ever bitten a person, child, or another animal?*

Yes
No
Unsure

If yes, please describe the bite situation detail

Interactions with other cats*

Please explain cat interactions (write "n/a" if this does not apply)*

Interactions with dogs*

Please explain dog interactions (write "n/a" if this does not apply)*

Interactions with children*

Please explain interactions with children (write "n/a" if this does not apply)*

Where does the cat spend the majority of its time?*

Indoor
Outdoor
Both

Is the cat afraid or fearful of anything? Please explain.*

How long does your cat spend alone on a typical day?*

What is your cat's activity level?*

Which of the following best describes your cat? Check all that apply.*

Does your cat have any other behavior quirks? (Ex: hates water, scared of cars, etc.)

Please summarize the cat's overall personality*

Please provide any additional information that will help the Behavioral Team in placing your cat in a forever home*