I, _______________________, am placing the following bird(s) in the

care of FlitesongCage Bird Sanctuary (hereinafter referred to

as 'FCBS'):

Bird’s Name:_______________________________________________.

Band #_______________________________Microchip ID__________.

Type and sex of bird:_______________________________________.

I am donating the following items to FCBS: _____________________

_________________________________________________________

By initialing the statements below and signing this form:

1._________I understand that immediately upon the physical transfer

of my bird to FCBS, it shall henceforth be in the care of and the

property of FCBS, meaning that I have no further claim on the bird

whatsoever, including future visitation rights or access to the name

of an adopter of this bird, unless that person agrees

I may contact them.

2.________ FCBS becomes immediately responsible for any veterinary

bills and holds me harmless from any negative result of accepting my

bird(s) into its care. I, in turn, hold harmless FCBS in the event my

bird(s) becomes injured, ill, or deceased while in FCBS’s care.

3._________FCBS, at its sole discretion, may choose to keep the

bird at the Sanctuary for an indefinite period of time or may choose

to adopt the bird to a suitable adopter in accordance with FCBS

guidelines and requirements. I further agree that any fees or

donations or fees, whether paid in kind or monetarily, that may be

received by FCBS in relation to an adoptive placement are the

property of FCBS.

4.___________ My veterinarian has been:_________________,

phone number________________, city ____________.  Further,

I hereby authorize the release of any records on this bird that are

in the possession of this veterinarian or veterinary clinic/hospital

to FCBS for the purpose of providing FCBS with a full medical history.

_________________________________________________________

Printed Transferring Owner's Name       Signature                  Date

===================================================

The undersigned FCBS Representative hereby accepts the bird(s)

and equipment/supplies listed above on behalf of FCBS.

_________________________________________________________

Printed Name                   Signature                                  Date