You can always press Enter⏎ to continue
FINANCIAL ASSISTANCE FORM

FINANCIAL ASSISTANCE FORM

Please complete this form to apply for financial assistance at our Marge Wright Veterinary Clinic. Thanks to the incredible generosity of our donors, we may have special grants and gifts available that to help community members who have low/limited income. By filling out this form, you understand that your story and photo may be shared with donors and/or online, including social medial. 
  • 1
    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    • Vaccines
    • Spay
    • Neuter
    • Vaccines with a Spay/Neuter
    • Medical
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    - 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
    Press
    Enter
  • 9
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 10
    Press
    Enter
  • Should be Empty:
Question Label
1 of 10See AllGo Back
close