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Application Form
Application for Free Spay and Neuter Funding
The funds available through the Mississippi Spay and Neuter Initiative are restricted to individuals in the State of Mississippi who need assistance with spay and neuter of multiple animals causing hardship and/or colonies of cats. All spay and neuters must be completed within a specified time-frame and a report of completion submitted with pictures. Please fill out the information below to be considered for funding.
Name
(Required)
Address
City
Zipcode
Phone Number
Email
Total number of animals
Female cats
Male cats
Female dogs
Male dogs
Are there any animals that will be left unaltered
Yes
No
Are any under 2 lbs in weight?
Yes
No
Total household income
Under $30,000
$31,000 to $55,000
$56,000 to $75,000
understand
I understand that the funds are strictly used for spay and neuter surgery and that any charge beyond the surgery I may be responsible to pay.
Signature
Date
MM slash DD slash YYYY
I attest that I am the owner / person to authorize veterinary treatment / surgery / sterilization for my pet. I have been informed and understand that there are risks inherent in any type of surgery and that in some cases, my pet may die or suffer serious effects during or after surgery. Knowing these risks and the dangers associated with surgery, I hereby release and discharge Mississippi Spay and Neuter Initiative, all officers and directors and fund sponsors from any and all actions, claims, damages, loss of services, expenses and compensation on account of the surgical services to paid for by the organization Mississippi Spay and Neuter Initiative and fund sponsors.
Signature
Date
MM slash DD slash YYYY
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