The “10th Life” Sanctuary, Inc.

provides lifetime care for sick, unwanted and feral cats

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A “no-kill” 501(c)(3)                                                                                    16601 State Road 80

not-for-profit charity                                                                                      Clewiston, FL 33440

(863) 902-9200a

SANCTUARY ADMISSION FORM

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The “10th Life” Sanctuary, Inc. hereby accepts the following described animal:

o ADULT CATo KITTENo FRIENDLY (can be picked up)o UN-FRIENDLY (feral)

o FAMILY PETo STRAY

Name of pet: __________________________ How long have you owned it?_____________

Where did you get it?_________________________________________________________

Veterinarian: ________________________________________________________________

Shots: _____________________________________________________________________

PHYSICAL DESCRIPTION:_________________________________________________________

______________________________________________________________________________

o Male; o Female; o Unknown;Weight: ______Color: _________________ Age: _______

Neutered/Spayed: o Yes; o No; o Unknown;Declawed: o Yes; o No; o Unknown;

Markings/Deformities: __________________________________________________________

Special Diet/Medical Conditions: __________________________________________________

Reason for Surrender: ___________________________________________________________

Animal’s owner:

Name: __________________________________________________________________________

Address: _________________________________________________________________________

City: _______________________________ State: ________ Zip:___________________________

Phone: _____________________ Drivers License #______________________________________

Email:___________________________________________________________________________

The owner hereby surrenders the above described animal — and all ownership and visitation rights to the animal — to The “10th Life” Sanctuary, Inc. The owner may not redeem the animal and “10th Life,” in its sole judgement, will decide if, when, and to whom the animal can be adopted. “10th Life” will only euthanize the animal if (a) the animal is suffering and is untreatable, or (b) “10th Life” has to go out of business due to a lack of funds and, prior to going out of business, can not find a suitable home for the animal.A

Date: ________________

Owner’s Signature: ____________________________________________________________________

The “10th Life” Sanctuary, Inc. representative: _____________________________________________