SS FINANCIAL ASSISTANCE FORM

1

Your Name

First Name

Last Name

2

Your Information

Please enter your phone

City that you live in

Zip code

3

Annual Household Income

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

4

Your Pet's Information

Pet's Name

Date of your pet's appointment

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What type of service are you receiving for your pet?* This field is required.

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How much can you contribute to your service?

Enter dollar amount

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Please tell us about your pet and how this financial assistance will make a difference for you and your pet. * This field is required.

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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).

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Please Upload a Photo of You and Your Pet.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Thank you to our generous funders, including PetSmart Charities, who help support the pets and people of our community.