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PAWS Services Application Form
PAWS Services Application Form
1. Application Details
Name
Name
First
First
Last
Last
Phone
Email
I am a/an:
Individual
Community Agency
Rescue Group
Other (Please, specify)
2. Animal Details
Animal Name
Animal Age
Animal Species
Animal Gender
3. Reason for Applying
I need help with:
Paying for emergency veterinary expenses
Paying for preventative veterinary expenses
Paying for spay/neuter/vaccination veterinary expenses
Educating the public
Other (Please, specify)
Please state the medical or safety emergency in question:
4. Qualification Criteria
If you are a member of the general public
, please answer the below:
Are you receiving government income assistance (e.g. GIS, ODSP, CPP, etc.)?
NO
YES, please state which:
What is your household’s annual income?
How many people live in your household?
Members of the public must attach proof of income or proof of their enrollment in a government program to their application form before their application can be processed.
If you reside in a residential facility
, please answer the below:
Facility Name:
Facility Location:
Facility Telephone number:
Name and email address of your counsellor/point of contact:
For all other individual applicants:
Are you otherwise in a crisis that presents a threat to the health or wellbeing of your companion animal? Please describe:
If you represent a community agency or rescue group
, please answer the below:
Name of group or agency:
Nature of group or agency’s services:
Reason for request:
5. Veterinary Details
Please complete if funds for veterinary services are being sought:
Name of veterinary clinic being used:
Clinic phone number:
Clinic location:
Name of presiding veterinarian:
Date animal was last seen by the veterinarian:
Veterinarian-recommended procedures required for the health of the animal (check all that apply):
Spay/Neuter
Vaccinations
Emergency prescription
Diagnostic testing
Emergency surgery
Other (Please, specify)
Estimate of cost of these procedures:
Amount of funds that applicant can contribute towards veterinary expenses:
Amount of funds requested from PAWS:
If you do not meet our application criteria or are otherwise in an exceptional situation that you feel warrants PAWS’ attention and assistance, please provide details below to support your application:
If you are human, leave this field blank.
Submit