Lake County Silver Foundation’s HELP A SENIOR SAVE A PET Application
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone Number
-
Area Code
Phone Number
Land Phone Number
-
Area Code
Phone Number
Age (Must be 60+ to be eligible for this program).
Approximate monthly income level
Type of Pet
Dog
Cat
Bird
Other
What services do you need assistance with?
Vaccinations
Adoption Assistance
Critical Grooming
Nail Trimming
Spay/Neuter Clinic
Minor Medical
Tick Removal
Fox Tail Removal
Dog/Cat Carriers
Leashes
Emergency Food
Water/Food Bowls
Cat Boxes/Litter
Other - please explain further below.
What is/are the issue(s) with your pet? Why is this important to you?
Do you have transportation?
Yes
No
Please verify that you are human
*
Submit
Should be Empty: