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Several Ways To Submit Application:

  • Print This Form And Submit By Mail Or Email (You may highlight and print or use a downloadable form for word processors below.)

  • Submit Form Online (see below)

  • Submit a form to a GCHS volunteer at an event.

 

Grainger County Humane Society

PET WELLNESS CLINIC APPLICATION

 

TODAY'S DATE:_____________

CLINIC REQUESTED: (location)______________________________________________________________

DATE OF REQUESTED CLINIC: (see clinic description)____________________________________________

Name ___________________________________________________________________________________

Address _________________________________________________________________________________

City/State/Zip _____________________________________________________________________________

Day Phone ______________________________ Evening Phone_____________________________________

Cell Phone_______________________________Email Address _____________________________________

1.    Pet's Name:______________________________             Dog             Cat               Age:_______________

        Breed:__________________________________            Male      Female               Weight:____________

        Services Requested:          Heartworm Testing  (dogs)                                        Feline Leukemia Testing  (cats)

                                                       Routine Vaccinations (feline or canine)                 Rabies Vaccination

                                                       Parasite Control (de-worm, flea control, etc.)

                                                            

2.     Pet's Name:______________________________             Dog             Cat               Age:_______________

        Breed:__________________________________            Male      Female               Weight:_____________

        Services Requested:          Heartworm Testing  (dogs)                                        Feline Leukemia Testing  (cats)

                                                       Routine Vaccinations (feline or canine)                 Rabies Vaccination

                                                       Parasite Control (de-worm, flea control, etc.)

                                                            

THESE CLINICS ARE OPEN TO ALL HOUSEHOLDS REGARDLESS of INCOME

By signing and submitting this application, I agree to accept a complimentary "Participating Membership" in the Grainger County Humane Society. Participating Members receive newsletters and information about upcoming events, meetings, and volunteer opportunities; but do not receive voting privileges.

Applicants signature _________________________________________________________DATE:_____________

If I am not chosen for this program, please keep my name on file for future pet wellness clinics.______________Initial

For office use only:#______________ Date_________________GCHS representative __________________________

MAIL YOUR APPLICATION TO:

Grainger County Humane Society

ATTN:  Pet Wellness Clinic Application

P.O. Box 229

Rutledge, TN 37861

 

You will be notified one week prior to clinic by phone or mail.

Make sure we have a working phone number.

 

Pet Wellness Application (Microsoft Word Format)

 

Pet Wellness Application (Online Submission)

Grainger County Humane Society

P.O. Box 229

Rutledge, TN 37861

 

graingerhumane@hughes.net

WebSite Designed and Maintained By GCHS Volunteer November 2008