THERE IS CURRENTLY A WAITING LIST FOR SPAY/NEUTER VOUCHERS. WE ENCOURAGE YOU TO COMPLETE THE FORM TO GET ON THE LIST. WE WILL REACH OUT TO YOU IF/WHEN WE CAN PROVIDE A VOUCHER. PLEASE PROVIDE A WORKING PHONE NUMBER AND EMAIL ADDRESS.

Are you a resident of Chesterfield County, South Carolina?
YesNo

How did you hear about the program?

Name

Your voucher will be mailed to you. Please provide a valid mailing address.

Phone Number

Email Address

Below are questions regarding your pet. Please provide as much information as possible. If you’re applying for multiple pets, please provide information for all.

Do you have a dog or cat?
DogCat

Is this pet currently and will remain a permanent part of your family?
YesNo

Name of pet

Gender of pet
MaleFemale

Age of pet

Weight of Pet

Breed

Is your pet an indoor or outdoor pet?
IndoorOutdoorBoth

If your pet is female, has she had a litter in the past?
YesNo

If yes, how many?

Where did you get your pet?
Adopted from a shelter/rescueFound/StrayBoughtGiftOther

Tell us a little about your pet. What makes them special to your family? What is their personality like?

Please attach a picture of your pet:

If you receive a voucher, may we use pictures/information about your pet(s) on our social media outlets, newsletters, and other marketing material? This information is helpful in raising funds to continue the program.
YesNo

I hereby certify that the foregoing information is true and correct and that I have not omitted anything which would make my application false or misleading.

I understand that my voucher will cover the spay/neuter surgery, pain medication, and rabies vaccine. Any additional services/charges must be paid by myself, the pet guardian.

By using the voucher, I understand that my pet may have a pre-existing condition, which may not be apparent at the time of surgery and could increase the anesthetic and post-surgical recovery risk. I agree that Angel’s Hope and/or the veterinarian providing services will not be held liable or responsible for any possible health complications arising from the services provided for by this voucher.

I agree to participate in this program, assume all risks, and voluntarily agree to this waiver of liability.

Signature

Date