Street Paws Outreach Request Form

Street Paws Outreach Request Form

This form must be completed by anyone requesting support for assistance from Street Paws. Unless requesting spay/neuter asistance, all pets age 6 months and older must be spayed or neutered unless medically prohibited. If medically prohibited, a letter from your veterinarian on their letterhead citing the specific reason will be required at the time of request. If not medically prohibited, proof of spay/neuter must be presented prior to receiving assitance. Note: for food requests, we cannot guarantee that we will have specific dietary food or a particular brand of food available. We are limited in how many people we can assist based on donations. We typically provide support in Henry County, GA. and surrounding counties.
The outreach-community services assistance is for adult residents of Henry and surrounding counties, showing financial hardship preventing them from taking care of their pets. The funds for this program are very limited and are accepted on a case by case basis, so it is important that we serve those who need our help the most.

I understand
Am I eligible to apply? To participate in this program, we require the following: Applicant must be 18 years or older. Only 1 applicant per household. A completed application. A dated letter stating you are currently receiving Government Assistance. Government issued photo ID. Proof of Residency.

I understand
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where did you hear about us?*

A friend or colleageGoogleFacebookOther
Have you applied for and been denied for the following:*

Care CreditScratch Pay
Information about your pet*
Name of Pet(s)*
Age of Pet(s)*
Weight of Pet(s)*
Breed of Pet(s)*
Color/Description of Pet(s)*
Has this pet(s) ever been to the vet?*
Are all of your pets spayed and neutered? If no, please explain. *
If you have a dog, does he/she need any of the following?*

Spay/NeuterRabiesDA2PPHeartworm TestBordatella (Kennel Cough) VaccinationDewormerMicrochipPet FoodPet supplies for ex: leash or collarSick Animal Care/Basic Veterinary CareVeterinary Care-EmergencySick Animal Care/Advanced Veterinary CareEuthanasiaI don't knowI have a cat
If you have a cat, does he/she need any of the following?*

Spay/NeuterRabiesFVRCPFIV/FeLV TestFeLV VaccinationDewormerMicrochipPet FoodPet supplies for ex: litter boxSick Animal Care/Basic Veterinary CareVeterinary Care/EmergencySick Animal Care/Advanced CareEuthanasiaI don't knowI have a dog
Amount you can contribute towards the cost of veterinary care?*
Current household income per month from all sources (before taxes)*
Please list any assistance programs from which your household receives help*
Any additional useful information? (In heat, has this pet ever given birth, not friendly, outdoor pet, feral)*
Please describe the assistance you need from the rescue and list anything else you would like for us to know. *
To ensure our resources are directed to those who require them most, we ask clients to submit one of the following documents to qualify for the program. Please inform us of the specific document you intend to provide.*

Public HousingSupplemental Security IncomeDisability/SSDMedicaidWelfareTemporary Assistance for Needy Families (TANF)Food Stamps (SNAP)WIC (Women, Infants, and Children)Food and Nutrition ServicesProof of income below 200% of the federal poverty level, which may include: A letter from the employer (on business letterhead, specifying company name, address, and phone number), unemployment forms, a notarized letter from the individual financially responsible for the householdOther
Participation Rules and Obligations: I understand my commitment outlined below, and will abide by the following rules and regulations regarding my participation in the outreach-community assistance program. a.) I understand that Street Paws reserves the right to terminate this agreement in protection of its organizational integrity if I fail to comply. b.) I agree to follow guidelines outlined by the program administrator and the veterinarian performing any treatment. c.) I agree to submit the requested documentation in order to receive services. d.) I agree to submit proof of residency (drivers license, utility bill, etc) e.) I understand that I am willingly agreeing to pursue veterinary services for my pet(s) listed above, and release Street Paws from all liability resulting from any veterinary services I receive from an independent veterinary clinic. f.) I understand that any additional veterinary services required for my pet(s) are my own financial responsibility, and I release Street Paws from any financial liability resulting from additional veterinary services. g.) I understand that Street Paws assistance is for pets owned by me (the applicant). The information I have provided about myself, my pet, and my household income are accurate and truthful. I certify that the information I have provided on this application is true and that giving any false information will result in the disqualification of this application and any future applications from Street Paws. h.) Fraudulent use of this program will result in services charged to me at full price and possible legal action against me and others involved in fraudulent use of this program.*

I have read, understand, and accept the rules and obligations for participation.
Upload copy of driver's license and proof of residency here

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