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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

SPAY/NEUTER APPLICATION FOR QUALIFYING CLINICS

TODAY'S DATE:_____________

CLINIC REQUESTED: (RAVS, Continuous Spay/Neuter, etc.)________________________________________

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:____________

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

        Breed:__________________________________            Male      Female           Weight:____________

THESE CLINICS ARE OPEN TO QUALIFIED LOW INCOME RESIDENTS OF GRAINGER COUNTY.

Please check all that apply to your family:

  Low Income Family (please enclose a copy of current paycheck stub)

  Receiving Federal or State Financial Assistance (please include a copy of your benefits letter)

  Senior Citizen/Disabled (please include a copy of your benefits letter)

Annual Household 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 spay/neuter clinics._______________Initial

Number of other animals in my care that need spaying or neutering:  Dogs________________ Cats________________

SUBMIT YOUR APPLICATION TO:

Grainger County Humane Society

ATTN:  Spay/Neuter Program 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.

For office use only:#__________ Date_____________GCHS representative ___________________

Qualified Application  (Microsoft Word Format)

Qualified 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