Southeastern Raptor Center Patient Admission Form Today's Date* MM slash DD slash YYYY Transporter Name* First Last Organization (if applicable) Transporter Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Transporter County* Phone*Email Is rescuer name same as above?* Yes No If no, enter name of rescuer and phone number: Is rescue location same as above? If no, enter rescue location including street address, city, county and state in fields below.* Yes No Rescue Location Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Rescue Location County* Date of rescue* MM slash DD slash YYYY Reason for Rescue (please be as specific as possible, i.e., cat/dog, found in road, etc.):*Have you offered the animal any food or water? If yes, what and when?*Any other treatments given?*Do you have a carrier/box that you would like to pick-up?* Yes No If yes, you must request and legibly complete a label, and place it on the carrier before you leave. **All carriers/boxes must be picked-up within seven days or they will be discarded.Would you like to be added to our mailing list? Yes No Triage HoursBy dropping this animal off for admission with the Southeastern Raptor Center, I acknowledge that all raptor intakes will be triaged during the hours of 8 a.m. – 5 p.m. daily. No medical care will be provided outside of these hours. Animals surrendered to the Southeastern Raptor Center become the responsibility of the Southeastern Raptor Center, in accordance with all state and federal regulations, and the transporter has no rights pertaining to the animal.Full Name* By entering your name here, you acknowledge that you have read and understood the triage hours of the Raptor Center above. Wild BirdI acknowledge that this bird was found in the wild and is not owned or permitted for use by the individual dropping off. Owned/Permitted birds cannot be dropped off with the Southeastern Raptor Center.Full Name* By entering your name here, you acknowledge that you have read and understood that this bird was found in the wild and is not owned or permitted for use by you. Interested in volunteering? Learn ways to get involved with the raptor center here.
