Peppers Broken Tails Grant

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Personal Information

Information About you

I

About your pet(s)

About Your Veterinarian and Your Payment

Other Info

Requirements and Signature

I affirm that the information I have provided is complete and accurate. I give my consent for the above-mentioned medical care. I understand that Broken Tails assumes no liability and makes no assurances as to the appropriateness, quality or outcome of any medical diagnoses, treatments, products or services. I consent to give Broken Tails use of any pictures provided of my pet or its owners as well as a description of the medical care to help in promotion and fund-raising. I understand any pictures given to Broken Tails cannot be returned.

In order to receive financial assistance for my pet, I must:

  • BE 18 YEARS OF AGE OR OLDER.
  • Have identification showing my present address.
  • Understand that this application is the property of Broken Tails. They have the right to verify my identity and retain the information in their files.
  • Understand that Broken Tails has full authority to approve or deny your application.
  • Understand that Broken Tails reserves the right to verify all information submitted on this application, including veterinary information.
  • Understand it is my responsibility to provide safe, warm, indoor housing for my cat/dog while he/she is recovering.
  • Understand that if the foster family has other cats/dogs that go outdoors that they need monthly heart worm, flea and tick preventative treatments.
  • Understand that I must provide quality food and access to water at all times.
  • Understand that I am responsible for giving my cat/dog post-operative care which may include medicine, therapy, and follow-up appointments as prescribed by my Vet. If I fail to comply with the post-operative care, all Broken Tails financial assistance may be withdrawn.
  • Understand that I must closely monitor the condition of my cat/dog and contact my Vet immediately when problems are observed.
  • Understand that all cats/dogs that receive Broken Tails funding MUST be spayed or neutered. I consent to have my cat/dog spayed or neutered during this procedure or within a set time frame after the procedure based on the health of the cat/dog.

By selecting ‘I Agree’ below, I affirm that I understand and accept Broken Tails requirements, payment policies, as outlined above and detailed on the Grants page. It also certifies that the information I have supplied above is true and that any false statements may result in nullifying this application. I further understand that this application is the property of Broken Tails and will be retained by them.

By selecting ‘I Agree’ below, it constitutes an electronic signature that is valid and a legal substitution for my written signature.


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