Individual Assistance Application
Please fill this form out honestly and completely
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Today's Date
*
-
Month
-
Day
Year
Date
Pet Name
*
Pet Type
*
Dog
Cat
Reptile
Other
If Other, describe
Pet Age
*
Picture of Pet
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Male or Female
*
Please Select
Male
Female
Spayed or Neutered?
*
Please Select
Yes
No
How long have you had this pet?
*
What is your primary need?
*
What prompted you to reach out for assistance?
*
Has this been a need in the past?
*
Please Select
Yes
No
What steps have been implemented as a remedy to the situation?
*
Is your Pet currently under the care of a Veterinarian?
*
Please Select
Yes
No
If yes, please provide Vet Clinic, phone number, case number if applicable and current estimate
Estimate if applicable
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If you are unable to receive assistance, what is the outcome for your pet?
*
Disclaimer
I understand that the statements above are true to the best of my knowledge. I understand that The Michael Movement does not always have funds available. I understand that submitting this application does NOT guarantee assistance. The Michael Movement strives to provide help where needed, but we are not always able to do so. The Michael Movement never gives funds directly to individuals. Assistance may come in a variety of forms including: reducing costs of emergency vet bills, providing food, funding medication, reducing costs of vaccinations, reducing costs of spay/neuter, funding necessary supplies for survival, etc. By signing below, I hereby indemnify and agree to hold harmless, The Michael Movement and it's directors, volunteers, and board members of any issues or damages caused by assistance.
Signature
*
Submit
Submit
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