
			Majestic Waterfowl Sanctuary, 17 Barker Road, Lebanon, CT, 06249
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Online Owner Surrender Form

Please complete the form below. After receiving the information we will contact you to discuss whether we can accept your duck or goose into our rescue shelter. All owner surrenders must be hand delivered to the Majestic Waterfowl Sanctuary or shipped at the owner’s expense.

Please complete a separate form for each duck or goose.

ATTENTION: If the bird(s) you wish to surrender are not located in the state of Connecticut, please click here before filling out the form below.

Owner Surrender Form

Information about the Owner

Owner's Name:

Address:

City:

State: Zip:

E-mail:

*If you enter an incorrect email address, we cannot respond to your inquiry. Double check it!

Telephone:

Time Zone:

ET PT CT MT

Contact Preference:

Email above Telephone above
Other: (Please explain)

Information about the Duck or Goose

Name:

Species:

Duck Goose

Breed:

Feather Color

Gender:

Male Female Don't Know/Unsure

Age:

years and months

Date of Hatch:

(If known)

How did you acquire this duck/goose?

How long have you owned this duck/goose? years and months

Primary caretaker of this duck/goose: Male Female

Age of Primary Caretaker:

Under 12 13-20 21-30 31-40 41-60 60+

Duck/goose kept primarily: Indoors Outdoors

Can this duck/goose fly? Yes No Wings Clipped? Yes No

Please describe the daily diet of this duck/goose:

If this duck/goose is FEMALE, is she currently laying eggs? Yes No

Have all eggs been normal with a smooth, hard surface? Yes No

If not, please describe any problems/irregularities:

What kinds of birds were kept with this duck or goose?

Number of Males
(List number) Number of Females
(List number)

None

Ducks

Geese

Chickens/Roosters

Turkeys

Why do you want to surrender this duck/goose?

Medical Information

Has this duck/goose ever been seen by a veterinarian? Yes No

If yes, please complete the following:

Vet's Name:

Address:

City:

State: Zip:

E-mail:

Telephone:

Date of last vet visit:

Please list any medical problems or physical disabilities:

Has this duck/goose ever experienced sudden drastic loss or gain of weight?
Yes No

If yes, please describe:

Has this duck/goose been wormed within the past three months? Yes No

If yes, when:

Brand/Type of Wormer Used:

Has this duck/goose ever had a disease or illness? Yes No

If yes, please provide dates and details:

Date:	Illness/Disease	Vet Seen?	Recovered?

		Yes No	Yes No
		Yes No	Yes No
		Yes No	Yes No

Has this duck/goose ever taken medication? Yes No

If yes, please provide dates and details:

Date:	Medication	Vet Prescribed?	Still Taking this Medication?

		Yes No	Yes No
		Yes No	Yes No
		Yes No	Yes No

Has this duck/goose undergone any herbal/alternative medicine or therapy?
Yes No

If yes, please describe:

Does this duck/goose have any current health problem, injury, or illness that
requires medication and/or specialized care? Yes No

If yes, please describe:

Please describe below any past health problems, injuries, or illnesses:

Behavioral Information

Does this duck/goose sometimes bite people or other animals? Yes No

Is this duck/goose imprinted on humans? Yes No

Please check the personality characteristics that best describe this duck/goose:

	Lap Bird: This duck or goose will walk up to greet their caretaker and loves to be petted and picked up.

	Welcoming: This duck or goose will walk up to greet their caretaker to be petted, but prefers not to be picked up.

	Friendly: This duck or goose will not approach their caretaker, but their caretaker can approach the animal and freely pet them. The animal prefers not to be picked up.

	Shy: This duck or goose will not approach their caretaker, but their caretaker can come within three feet of the animal. The animal will sometimes allow limited petting.

	Timid: This duck or goose will run approximately between five and ten feet away from their caretaker before stopping. They will rejoin the flock once the caretaker has backed away.

	Nervous: This duck or goose will run from their caretaker and keep on running. The animal is fearful of humans to the point of risk of self-injury or escape.

	Aggressive: This duck or goose will chase and attempt to bite their caretaker.

Please list anything else you think we should know about this duck/goose:

Please describe the daily routine of this duck/goose:

Acknowlegement

By submitting this form, I certify that the information provided within is true and accurate. I understand that Majestic Waterfowl Sanctuary retains the right to decline the acceptance of this application, and I further understand that they are in no way obligated to provide me with an explanation for my duck or goose not being accepted into their rescue program.

Release of Veterinarian Records