Misfit Wheels Application

Welcome to the application for the Misfit Wheels program. At this time, the program is limited only to residents of Manatee, Pinellas, Hillsborough, and Polk counties.

Though we aim to help as many pets as possible, please understand that spots are limited and application to the program does not guarantee admission.

Please begin your application by entering your pet’s name below:

Pet’s name

Pet’s age

age of pet

What breed is your pet?

What is the sex of your pet?

Owner’s Full Name*

First NameLast Name

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number - Home

Area CodePhone Number

Phone Number - Cellular

Area CodePhone Number

Do you live in a:

Tell us a little bit about your pet and his/her mobility needs. Please be as specific as possible, including when the mobility issue began, if known. *

How much does your pet weigh (it’s ok to guess if you don’t know)*

Has your pet had a recent limb amputation?

YesNo

Does your home have stairs?

YesNo

Who is your pet’s primary veterinarian?

Veterinarian name and/or hospital

Are you a military veteran?

Is your pet diagnosed with a terminal condition?

YesNo

Do you receive any type of government assistance (Medicaid, WIC, SSI, SNAP etc).?

YesNo