Please fill out all required fields before clicking the submit button. You will receive a red error message under the field requiring information before your application can be submitted.
*indicates a required field

Applicant's Full Name*

Owner's Full Name (if different from Applicant)

Animal companion species: Cat(s), Dog(s), Rabbit(s), Guinea Pig(s), Bird(s); other*:

MaleFemaleDomesticFeral

Your Pet(s) and/or Rescue’s name(s); if Feral, write “N/A”*::

If recently rescued, please explain in a few words (date, location):

Does your pet and/or rescued animal need a Rabies Vaccination?*
[radio* need-rabies use_label_element "Yes" "No"]

If no, current on Rabies vaccinations?:
[radio* current-rabies use_label_element "Yes" "No"]

Age(s) if known:

How long have you had him/her in your care?*

Description of Type(s)/color(s)*

Current Veterinary clinic*

Veterinary Clinic Telephone Number*

Current Medications, if any

Your Email*

Your Contact Telephone Number*

Your Mailing Address*

City*

Zip Code*

Please complete all requested information above. You can email additional information or requested files to: nineveh@paloaltohumane.org

By clicking "submit", I authorize the veterinarian/s to discuss my animals’ health records and care with Palo Alto Humane (PAH). I also authorize PAH, if funding is approved, to share my animal’s information and photographs as PAH sees fit. I attest that the information I provide is true and correct and I am applying for assistance because I am in financial need, and I desire to spay and/or neuter my pets. I release PAH from any and all liability connected with any assistance I may receive.

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