SURRENDER
FORM
For the Love of Parrots Refuge Society (FLOPRS)
2116 Alberni Highway
Box 645
Coombs, B.C. V0R 1M0
250-248-5194 info@worldparrotrefuge.org | www.worldparrotrefuge.org
Information provided in this Surrender Form will help us understand your bird's needs.
Contact Information
Bird's Name ________________________________ Species __________________________
Guardian's Name_________________________________________________________________
Address ______________________________________________________________________
City ________________________ Prov/State _______________ Postal Code _______________
Home Phone __________________________ Work Phone _____________________________
Fax _______________________ Email _____________________________________________
I hereby authorize the release of ALL veterinary records pertaining to the above listed bird(s) to
representative of FLOPRS.
Instructions: ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I, ________________________________________ hereby donate to FLOPRS, the above listed bird(s) to be
housed at the World Parrot Refuge. I relinquish claims to the above listed bird(s) and any future property.
____ I would like to Virtually Adopt my bird ($500 covers the annual expense to house one healthy bird)
I understand that my bird will not be sold or adopted out for a fee and would like to provide financial
support to the World Parrot Refuge in the amount of $ _________________
____ Single donation
____ Remind me annually
___________________________ ___________________________
____________________
Donor's Signature (Guardian)
Date
Print Donor's Name (Guardian)
The above mentioned bird(s) has been accepted for FLOPRS by:
___________________________ ___________________________
____________________
FLOPRS Representative Signature
Date
Print FLOPRS Representative Name
Contact Information
Bird's Name ________________________________
Species __________________________
Hatch Date __________________________________ Age _____________ Sex (if known)  M  F
How and when was the sex verified? _______________________________________________________
When did you acquire your bird? _________________________________________________________
 Pet Store  Breeder  Animal Shelter  Bird Club
 Friend or Family  Gift  Other ________________________________
Where did you acquire your bird?
 Private Party
Please provide contact information for your bird's breeder, pet shop, or previous guardian:
Contact Name _____________________________ Store/Business ______________________________
Address ______________________________________________________________________
City ________________________ Prov/State _______________ Postal Code _______________
Phone ____________________________
Email ____________________________
Veterinary Information
Please obtain complete vet records and attach to this Surrender Form.
Do you currently have an avian veterinarian?  Yes  No
If yes, please provide contact information
Avian Vet's Name ____________________________ Clinic Name ________________________
Clinic Address _________________________________________________________________
How often do you take your bird to the vet? _________ When was your bird's last vet visit? __________
What was the reason for the visit? ________________________________________________________
 Yes  No
Is your bird DNA registered?  Yes  No
Is your bird banded?
If Yes, what band?
____________________________
If yes, with whom? ______________________________
Describe your bird's overall physical condition _______________________________________________
______________________________________________________________________________
______________________________________________________________________________
Has your bird ever sustained any injuries?
 Yes  No
If yes, please describe
____________________
______________________________________________________________________________
Has your bird ever had any surgeries?
 Yes  No
If yes, please describe and give reason(s)
___________
______________________________________________________________________________
Has your bird ever been treated for any diseases?  Yes  No If yes, please describe _____________
Has your bird ever taken any medications?
 Yes  No
If yes, please describe and give reason(s)
_______
______________________________________________________________________________
Has your bird ever been on herbal or other alternative therapies?  Yes  No
If yes, please describe
and give reason(s) ________________________________________________________________________
Does your bird have any medical/physical conditions that requires treatment and/or a specialized
caging/play area?  Yes  No
If yes, please describe ________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Any other pertinent information?
______________________________________________________________________________
______________________________________________________________________________
Information is confidential. The World Parrot Refuge operates solely on donations from individuals like yourself.