REQUEST FOR ASSISTANCE

Click here for a printable Application for Assistance.

Your First Name *

Your Last Name *

Street Address or PO Box

City, State, Zip

Phone *

How did you hear about our organization?

Basic Household Information

Do you ... *

Own

Rent

Live with family

Other

Are you an enrolled member of the Eastern Band of Cherokee Indians? NOTE: this question is ONLY for statistical information *

Yes

How many children live in your household? *

Please tell us about the pet that needs our help. If there is more than one pet, please note that in the comments section and choose one to describe below.

Name of Pet *

Species * Species

Breed *

For example: Siamese, domestic short hair, mixed, german shepherd, schauzer, cockatoo, etc.

Age *

Sex * Sex

Is this pet spayed or neutered? *

Yes

Not Applicable

Is this pet up-to-date on shots? *

Yes

OtherOther

Is this pet on flea/tick preventative? *

Yes

I don't know

Is this pet on heartworm medication? *

Yes

I don't know

Where is this pet housed? *

Indoor

Outdoor

Both

Other

If Outdoor, Both, or Other, please describe pet's containment and housing

We ask where the pet is housed because if surgery is necessary, and for spay/neuter, there is usually a requirement for animals to be kept quiet and contained. We must know that you are prepared for this possibility, or that you will work with us for arrangements to be made for this to be accomplished.

Do you have an established relationship with a veterinary clinic? *

Yes

NOTE: This does not include an emergency vet clinic you are utilizing currently. This would be a veterinary clinic you take your pet(s) to for routine preventative care such as rabies shots, check-ups, etc.

If yes, which clinic?

Is this a major or emergency situation? *

Yes

I don't know

Please explain the situation: *

Please provide any other information from the veterinarian that would be helpful to us:

Do you have any other comments regarding your situation?

Do you receive government assistance? (ex: food stamps, Medicaid, low income housing) *

Yes

If yes to government assistance, please provide type of assistance

Has your household income been impacted by the COVID-19 pandemic? *

Yes

Are you able to contribute additional funding beyond what AAJC can contribute? (e.g. Care Credit or ScratchPay) *

Yes

I don't know

If yes, please explain:

Please explain your financial hardship and tell us why you have reached out to us. The more information we have about exactly what you are asking assistance for, the better we will be able to help you. *

Advocates for Animals in Jackson County, Inc. requires all funding recipients to:

Consider a future monetary donation when your financial situation improves.
Consent to follow-up phone calls/emails from an AAJC representative within 2 weeks, 6-months, and 1-year post-assistance. If AAJC does not hear back after two attempts to contact you, you will not be eligible for any future assistance from AAJC.
Inform AAJC if your address and/or phone number changes during the 12-month post-assistance period.

By entering my name below and submitting this form, I certify that I am agreeing to these requirements and that the answers on this application form are true and correct to the best of my knowledge. I agree to release Advocates for Animals in Jackson County, Inc. and its service providers (veterinarians, trainers, and fosters) from liability should the veterinary care, foster care, or behavioral training rendered prove unsuccessful or the animal becomes ill or injured while in our care.

Do you agree to all requirements? *

Yes

Type your name below: *

If you are human, leave this field blank.

Advocates for Animals of WNC

A 501c3 created for the health and welfare of companion animals and the people who love them

REQUEST FOR ASSISTANCE