Community Outreach Form

Name of dog's owner or primary caretaker: *

Address *

City: *

State: *

Zip/Postal Code: *

Phone Number: *

Email (please use an email address you are able to check often): *

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What is your dog's name: *

What is your dog's age? *

What is your dog's weight (lbs)? *

What is your dog's gender? *

What is the breed of your dog? *

Dogs Color *

How long have you had the dog? *

How many other animals living in the home? Please list names, breeds, and age. *

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Veterinarian's name? *

Veterinary hospital or clinic name: *

Address: *

City/State/Zip: *

Phone Number: *

Is your dog up-to-date on vaccines? If not which vaccines does your dog need. Check ALL that apply. *

Dog is Current on Vaccines

NEEDS-Rabies

NEEDS-Puppy DHPP: vaccines for Distemper, Adenovirus (Hepatitis), Parainfluenza and Parvovirus

NEEDS-Adult DHPP: vaccines for Distemper, Adenovirus (Hepatitis), Parainfluenza and Parvovirus

What services are you needing assistance from SEPR with? *

Total Amount requested: *

Are there circumstance that we need to be aware of (i.e. termination of pregnancy, pediatric spay, undescended testicle etc.) that would make the procedure more costly? If yes, please explain: *

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How many individuals reside in your home? Please list ages. *

Your average annual household income? *

Does your household receive any public assistance? *

How much can you contribute toward the cost of care? *

Have you applied previously with SEPR for assistance? *

Yes

No

How did you hear about SEPR's spay/neuter assistance program? *

Any additional comments you would like to give for consideration of this application: *

Please attach current vet records:

Please attach current photo of your pet in need.

Spay (female)	Neuter (male)
Vaccinations	Micro-chipping
City License	Education
Behavioral Training	Other Other

$0-$10,000	$10,000-$20,000
$20,000-$30,000	$30,000-$40,000
$40,000-$50,000	$50,000 +