NKy Emergency Pet Resources Assistance Application
** PLEASE NOTE! WE DO NOT DELIVER. ** In an effort to provide expeditious service, we have set up pre-arranged distribution locations and times, based on geographical locations. You can find those days and locations on our Facebook page. If you need urgent service, within 24 hrs of applying, we will make every effort to set up a distribution based on your location. Your application will be cancelled if we have no response after 24hrs of attempting to arrange a distribution date and location. At that point, you will need to reapply for reconsideration.
Your Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Is this a cell phone or landline?
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Please Select
Cell Phone / Mobile
Landline
Email
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example@example.com
City
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County
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Today's Date
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Month
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Day
Year
Date
Please explain why you are seeking assistance from NKyEPR.
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Name, Age & Breed of Pet #1
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Name, Age & Breed of Pet #2
Name, Age & Breed of Pet #3
Name, Age & Breed of Pet #4
Name, Age & Breed of Pet #5
Name, Age & Breed of Pet #6
If necessary, please list additional pets here
Animals in your home needing assistance
Dog
Cat
Rabbit, Guinea Pig, Ferret, etc.
Food
Litter
Litter Box / Scoop
Collar / Harness
Leash
Cage / Carrier
Puppy Pads
Additional Resources Needed
Dog
Cat
Rabbit, Guinea Pig, Ferret, etc
Routine Vaccines
Monthly Preventative
Spay / Neuter Surgery
Surgical Intervention Please explain below
MEDICALLY NECESSARY Grooming
Training Concerns Please explain below
End of Life Euthanasia
Any additional info can be provided here. Please explain any Additional Resources listed above.
Where did you hear about us?
PLEASE NOTE: NKyEPR, will provide 1 month’s supply at a time, to help keep your pet fed, and in their home. Every effort should be made, by the applicant, to provide for the pet themselves, with NKYEPR being a TEMPORARY solution only. If we find that our resources are being misused or your are applying under false pretenses, your application will be declined and future consideration will not be made.
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Please Initial Below as Read and Accepted
AGREEMENT: By signing below, you agree that the information provided here is true and accurate. You agree that you are not taking unneeded supplies / resources and will not attempt to profit by reselling those items. You agree, by your signature, that you will use the food and supplies for your personal pets only and not disperse them to any other person or organization. By receiving resources from NKYEPR your personal data will be compiled in a confidential log of individuals served and their pets, as well as which goods/services are offered. We may, at times, use your data for statistics only, never identifying individuals receiving assistance. You understand your pet may receive food they are not currently consuming, and as such, agree NKYEPR is not liable if your pet experiences any issues related to difference in food type, brand, etc. You understand and acknowledge that the food you receive is provided as a charitable donation and NKYEPR holds no responsibility to your pet’s overall health, as such, from these donations.
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Date
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Month
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Day
Year
Date
Submit
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