Request for Assistance
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Can we text you at this number?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
We utilize email as our primary mode of communication. Kindly check your email for any relevant correspondence. Should you lack access to your email account, you may send us a message through The Dog Stays Facebook page after completing the provided form. If neither of these options is suitable, please indicate your preferred method of communication.
Call, Text, Email, Facebook Messenger...
Please specify the Missouri county in which you reside?
*
Webster
Christian
Greene
Other
What is your age group?
*
Please Select
Under 18
19-62
65 - 75
Over 75
How many adults live with you?
How many children live with you?
How may we assist you today?
I need dog food.
I need a microchip.
I need a dog spayed/neutered.
I need vaccination assistance.
I need help with Respite Care.
I want to volunteer.
I want to donate.
I need supplies.
I'm interested in co-parenting a dog through your senior program.
I'm interested in adopting a dog.
Other
How Many Dogs Needing Assistance
*
Tell Us About Your Dog(s) or pet(s) in detail:
*
Name, Age, Breed, Weight, Health. Spayed/Neutered
Has your dog(s) ever bitten a person?
*
YES
NO
Dog was provoked
Only around food
Has your dog(s) ever bit another animal or pet?
*
YES
NO
High Prey Drive
Only Around Food
Other
Do you drive or have transportation? Let us know if you are able to pick up food or get your pet to an appointment or need assistance.
*
Any other information you want to share with us?
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