Application For Qualified Spay/Neuter Clinics

CLINIC REQUESTED:                                  Please Choose Clinic RAVS Continuous Spay/Neuter

DATE OF REQUESTED CLINIC:                 (see clinic description for dates)

LOCATION OF REQUESTED CLINIC:    (see clinic description)

Name:   

Address:

Day Phone:              

Evening Phone:       

Cell Phone:               

Email Address:        

PET #1

Name:       Dog          Cat              Age:

Breed:   Male  Female       Weight:

PET #2

Name:     Dog          Cat               Age:

Breed:    Male  Female       Weight:  

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

Accept Participating Membership

Please keep my name and pets on file for future spay/neuter clinics.

Number of other animals in my care that need spaying or neutering:  Dogs     Cats

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