Paws Services Application Form

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PAWS Services Application Form

1. Application Details

Name *

Name

First

Last

Phone *

Email

I am a/an:

Individual

Community Agency

Rescue Group

Other (Please, specify)

2. Animal Details

Animal Name *

Animal Age

Animal Gender *

Animal Species *

Dog

Cat

Other

Describe if other

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:

Describe Source of income

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

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:

Please check the box below to confirm that you have given your consent to the following: *

PAWS reserves the right to use your story and pictures of your animal companion for future advertising and fundraising purposes. PAWS will NOT use your name, personal information or reveal your identity in any way, which insures absolute privacy, unless you provide us with a written consent to do so. *

*

I consent to PAWS contacting my veterinary clinic regarding my application for funding. *

If you are human, leave this field blank.

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