SM FINANCIAL ASSISTANCE FORM

1
Your Name* This field is required.
First Name
Last Name
2
Your Information* This field is required.
Please enter your phone
City that you live in
Zip code
3
Annual Household Income* This field is required.
Less than $15,000 per year
$15,000 - $25,000 per year
$25,001 - $35,000 per year
$35,001 - $45,000 per year
More than $45,000 per year
Other
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Your Pet's Information* This field is required.
Pet's Name
Date of your pet's appointment
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Do you have a....* This field is required.
Cat
Dog
Both
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What type of service are you receiving for your pet?* This field is required.
Medical
Vaccines
Surgery
End of Life Services
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How much can you contribute towards your services?* This field is required.
Enter dollar amount
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How will this grant funding help you and your pet? This information may be shared with grant funders if you are awarded financial assistance.* This field is required.
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Please upload a photo of your Drivers License or State ID* This field is required.
Drag and drop files here
Select files to upload
Cancelof
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Please upload a photo of your pet* This field is required.
Drag and drop files here
Select files to upload
Cancelof
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Photo Release Agreement:* This field is required.- I understand that my story and photo may be shared with donors and/or online, including social medial. - I hereby sell, assign, and grant to the Arizona Humane Society and its assignees the right and permission to copyright and/or use and/or/ public photographic portraits, pictures, and/or video images of me or my minor child in which I or my micro child may be included in whole or in part r composite or reproduction thereof in color or otherwise made through any media at the Arizona Humane Society's locations or elsewhere for art, promotion, advertising, trade, or any similar lawful purpose whatsoever. - I hereby waive my right to inspect and/or approve the finish product or copy that may be used in connection wherewith. I understand that I will not receive compensation, either monetary or otherwise, in exchange. On behalf of myself and my minor child, I agree not to accept any money or compensation from anyone as a result of or in connection with my or my minor child's appearance or inclusion in any media produced by the Arizona Humane Society. - I hereby release and discharge the Arizona Humane Society, its successors, and persons acting under its permission or authority or those whom it is acting from any liability by virtue of blurring, alteration, optical illusion, or use in composite form that may occur or be produced in the taking of such picture or in processing tending toward completion of the finished product. - These photographs/video images may be used only by the Arizona Humane Society and its assignees for marketing and communication purposes (and as noted above).
I Agree
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IMPORTANT: Coverage of financial assistance is subject to change based on the availability of funding we have at the time of services. Thank you for your understanding!
Please Select
Please Select
I Understand
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Thank you to our generous funders, including PetSmart Charities, who help support the pets and people of our community.
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