MAC Pet Assistance Request Form

Name

First NameLast Name

Email

example@example.com

Address Where You Are Currently Residing:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What type of address is this?

Cell Phone Number

Please enter a valid phone number.

Email

example@example.com

How would you prefer to be contacted?

Please provide proof that you currently reside in Hamilton County, TN (e.g. photo of driver's license, mail, etc.)

Please tell us what kind of assistance you are hoping to receive (please note that our funds are very limited, and we sadly cannot fulfill all requests for assistance) NOTE: funds for emergency veterinary care are not available at this time:

If you are in need of emergency boarding for your pet(s), please tell us what agency(ies) you are currently partnered with for assistance (e.g. Red Cross, Family Justice Center, etc.):

Please describe your current situation, including the financial issue or hardship that has prompted this request for assistance (if applicable):

Is anyone in your household currently receiving some form of state/federal financial assistance?

How many people live in your home? Please list the number and ages of individuals (humans only please!) in your household:

Please tell us about your pet(s) (select all that apply):

	Cats	Dogs	Birds	Small Animals	Other
None
1
2
3
4
5 or more

Will you keep your pet(s) if MAC is able to provide assistance?

YesNoUnsure