SAVE Pet Assistance Registration Form

SAVE Pet Assistance Registration Form

Madison County Kentucky
Please read and state that you understand the below requirements and guidelines for Kentucky SAVE Pet Assistance Program.
Please answer all questions truthfully. All information is confidential, false information will be cause for denial. You must be able to agree to all statements to be eligible for assistance.
Requirements and Guidelines
SAVE Pet Assistance provides pet food and supplies as a SUPPLEMENT to your pets diet and needs. The amount received may not be enough to provide for all your pets needs. You will still need to attempt to provide what is necessary for your pets.

You understand that all pet food and supplies are donated to SAVE Pet Assistance. We cannot guarantee specific brands, food types, amount of food, or any sort of consistency in donations available. We will make every effort to consider your special requests but are only able to provide what has been donated and is available at that time.

Recipients agree to not resell, distribute, or attempt to return to a store any food or care items received from SAVE Pet Assistance.

You agree to not hold SAVE Pet Assistance, any volunteers or benefactors legally liable in the unfortunate event your pet(s) become ill or the food/ treats provided upset your pet(s) stomach.

Amount of donations are provided based on vet recommendation for your pets breed, age, and ideal weight.

We can provided no more than 50lbs of dog food a month to each recipient but adjustments will be made based on donations available. If inventory is low then amounts provided will be lowered. Donations can only be provided while supplies last.

You understand that food is to be fed to the appropriate animal. We will not provide dog food for cats or vise versa.

We will have pick up available the first Wednesday of every month. If you are without transportation, please note below and we will discuss delivery methods if possible. After two missed pick ups, recipients will be dropped from the program.
In regards to the above statements I....*

AgreeDo NOT Agree
Only one applicant is allowed per household to apply for assistance.

Recipients must be 18 years of age or older.

Recipients must reapply every 4 months for assistance to enusre food is being provided for those still in need.

Assistance will be provided for Madison County Kentucky residents only.

We have the right to inspect your home/ living space and meet your pet(s) prior to acceptance.

Applicants must be able to provide:
*Photo ID
*Proof of address or homelessness
*Proof of unemployment, income status, government assistnace, or disability

Two consecutive attempts will be made to contact you in regards to your registration, after two unsuccessful attempts your application will be denied and you will need to reapply.

We have the right to deny any applicants.
In regards to the above statements I....*

AgreeDo NOT Agree
Recipients must have owned their pet for at least 6 months before applying for assistance

Pets must be given (to the best of your abilities) proper care, shelter, a healthy and safe living environment.

Assistance will be provided for no more than 5 pets.

Any pets receiving assistance must be for companionship. Assistance will not be provided for breeders or any animals used in illegal activities.

Recipients cannot take on any additional animals while receiving assistance from SAVE Pet Assistance.

If a recipients pet has specific medical needs we will do our best to ensure donated items that suit their needs are given. A note from a vets office must be provided to be eligible for specific items. We cannot make a guarantee that their needs will be met but we will provide as best as we can as donations allow.

If evidence of abuse or deception is found you will be permanently removed from the program and cannot reapply for assistance.
In regards to the above statements I....*

AgreeDo NOT Agree

Registration

Please fill out entirely.
Name*

First NameLast Name
Date of Birth *
Drivers License/ State ID Number
Email
example@example.com
Living Conditions*

Own HomeAppartmentSection 8HomelessHotel/ Motel/ Temporary housing
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
If you do not have a phone number or fear you may not answer the number listed, please provide a secondary form of contact
Do you have a vehicle/ transportation for donation pick up? *
Job status*

Full timePart TimeUnemployedDisability

Pet Information*

	Name	Dog/ Cat	Breed	Age/ Weight	M/ F- Spayed/ Neutered	Date of last vet visit	Length of ownership
1
2
3
4
5

Upload proof of ownership (Vet records, adoption documents, photographs)

*Animals purchased from a breeder or pet store within the last year will not receive benefits
Cancelof
List any special needs or medical requirements your pets have:
Current or past vet clinic information (Name and phone number)

Why are you requesting assistance? *
Household Size*
Please list all adults (18+) and Children (0-17)
Does anyone in your home have veteran status?

Yes, myselfYes, family memberNo
Annual gross income: *
Upload proof of financial difficulty

Examples: Unemployment, disability, Social Security, proof of government assistance (Medicaid/Medicare, WIC, food stamps etc.)
Cancelof
Upload Photo ID

All Items for Upload can be emailed to FPUANDSAVE@gmail.com if unable to upload. Please include name listed on the application as well as the date the application was submitted.
Cancelof
How did you hear about us
I, Full Name* , certify that all information is filled out truthfully and agree to all rules and regulations listed in this registration. I understand that SAVE Pet Assistance has the right to deny any applicant and do not hold SAVE liable for any reaction my pet may have to items donated by the SAVE Pet Assistance Program Initial* Date*
Signature*

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SAVE Pet Assistance Registration Form

Requirements and Guidelines

Registration