Humane Society of Montgomery County

Application for Spay/Neuter Assistance

_________________________________________________________________________________

Name:____________________________________________________________________________________

Address:__________________________________________________________________________________

Home Phone:____________________  Cell Phone:___________________ Work Phone:__________________

To help us assist you in the most efficient manner, please read carefully and complete all portions of this application. Incomplete applications will not be processed and therefore we will not be able to assist you. It is important that you list all the dogs and cats currently in your care as well as all animals needing to be spayed or neutered. THE HSMC WILL ONLY KEEP YOUR APPLICATION ACTIVE FOR 30 DAYS AFTER WE CONTACT YOU.

LIST ALL DOGS AND CATS WHO CURRENTLY RESIDE IN YOUR HOME ON OR YOUR PROPERTY.                (ANY ANIMAL YOU OWN OR ARE CURRENTLY FEEDING MUST BE LISTED ON THIS APPLICATION)

DOGS-Please list all dogs in your care below (if you need more space, use the back of this form)

CATS-Please list all cats in your care below (if you need more space, use the back of this form)

PLEASE LIST ALL ANIMALS IN YOUR CARE WHO NEED TO BE SPAYED/NEUTERED BELOW

(if you need more space, please use the back of this form)

Veterinary clinic that gave the animal vaccines____________________________________________________

*If the cat(s) you have are feral/wild (you cannot touch them or pick them up):

Will you need a trap to catch them?    YES       NO        Do you have your own trap?   YES    NO

Will you be able to get the animal(s) to the veterinary clinic on their appointment date?   YES      NO*  

*If NO please explain (for example – I don’t have a car, I don’t have a carrier, it’s too big,etc)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How much can you afford to pay? $5.00    $10.00    $20.00   $25.00   $30.00  Other____________________

Have you had an animal spayed or neutered through the HSMC before?  YES      NO

If yes- How many?_______________   Cats or Dogs? ____________ Are you still caring for them? YES   NO*

*If No- where are they now?__________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________

Every effort will be made to work with you and your schedule to get our animal(s) spayed or neutered.  Animals are normally dropped off at veterinary clinics between the hours of 7:30AM and 9AM. Are there any upcoming events, dates, time you know will not work for you?________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________

I certify that all information given on this application is true and correct to the best of my knowledge. I have omitted nothing that would make this application false or misleading.

I understand that the HSMC will only provide assistance for the spay or neuter surgery; any other costs incurred (vaccines, pain medications, tests, etc.) will be my responsibility unless approved prior to surgery.

The information given on this application will never be released to any other person or organization. The information given on this application used to determine assistance needed to refine our program and assist the animals of Montgomery County.

Signature__________________________________________ Date_______________

**Please return completed application to:

hsmcspayneuter@hotmail.com

 or

HSMC Spay Neuter Program

1183 Flanagan Drive

Christiansburg, VA 24073