277-5595

Low-Cost Spay/Neuter Clinic Application

Alley Cat Rescue is a nonprofit organization, servicing the community, locally, nationally, and internationally, solely on donations/contributions and grants. The work of ACR is dependent upon its members, their generosity, and individuals like you! Tax-deductible contributions are welcome and will assist in furthering ACR’s ability to save abandoned/stray cats and allowus to fund programs, such as our low-cost spay/neuter clinic. Thank you for your time and support.

Do I qualify to participate in the low-cost spay/neuter clinic?

Ifyou reside in Maryland, Virginia, or Washington, DC and your household’stotal yearly income (from both partners, both spouses, or parents if you live at home) is$35,000 or less, thenyou qualify.

If your income is too high, but you want to request our help due to SPECIAL CIRCUMSTANCES:

complete the application, and attach your proof of income, and a brieflettertelling us why you need our financial assistance. We’re sorry, but we can’t guarantee that we can help you if yourincome is over the limit.

**** Please note: All information is completely confidential, and never shared or sold.****

PLEASE PRINTNEATLY. No declawing of cats will be done in conjunction with this program!

Your name:______

Address:______

City, State, Zip:______Your date of birth:______

HOME Phone:______CELL Phone:______Email:______

How do I prove that my income qualifies me to participate in the low-cost clinic?

What is your household’stotalincome? $______per week, month or year?

How many children under 18 do you support? ______

As proof of household income, you MUST submit one of the following items - block out Social Security numbers first.

  1. For working individuals, a copy of the first page of your and your spouse’s most recent tax returnor W-2.
  2. For fixed income clients, a copyof your most recent S.S., welfare, or disability check or benefits statement.

DOCUMENTS CANNOT BE RETURNED. THEY ARE DESTROYED AFTER VERIFICATION, TO PROTECT YOUR PRIVACY.

Cat # 1
Name of cat: / Age:
Male or Female? / Hair Length: (short, medium, or long?)
Color/Description of cat:
Cat #2
Name of cat: / Age:
Male or Female? / Hair Length: (short, medium, or long?)
Color/Description of cat:

If you have more than 2 cats that need to be fixed, please use the back of this page to provide their descriptions (name, sex, age, hair length, color/description).

Does/do the cat(s) have a current rabies vaccination? Yes No Not sure (If yes, be prepared to show proof.)

Does/do the cat(s) have a current distemper (FVRCP) vaccination? Yes No Not Sure (Please provide proof)

VERY IMPORTANT!

The program cost ONLYcovers the spay/neuter surgery & rabies & distemper vaccinations.

$60for malesand $60for females

Other services will require additional costs.See listing below.

Would you like other services performed, at additional cost(s)? Yes No

What services would you like to be performed? (check all that apply)

□ Pre-surgery blood work $69.00 (pets over 5yrs old require bloodwork)

□ Leukemia/FIV testing $20.00

□ De-worming $24.50

□ Flea treatment $16.00 (Revolution – one dose treatment good for a month)

□ Ear cleaning $25.00

□ Nails trimmed $10.00

□ Microchip $10.00

□ Other ______

□Pain medication $30.50 □Antibiotics $39.98 □E-Collar $19.43

(These are optional. All cats are given a pain injection and antibiotic injection at no additional cost.)

READ THIS BEFORE YOU SIGN! I hereby affirm that all information submitted in this application is true and correct, and I have not omitted anything; which would make this application false or misleading. I have disclosed my household’s total income. I am applying for MY OWN USEONLY. I understand that ACR may use any and all availableresources to verify the information I have submitted in this application. I understand that if I have violated any of these terms, or supplied fraudulent information, I will be permanently disqualified from ACR’s programs.

Your Signature: ______Date: ______

DID YOU REMEMBER TO:

~Fill out the application completely? Incomplete applications will not be processed.

This is the mostcommon reason that applications are rejected!

~Attach your PROOF OF INCOME? Applications cannot be accepted without it.

~Keep copies of all paperwork, in case you need to apply in the future? You must submit another applicationand proof of income EACH TIME you need to use the clinic.

~ Please ensure all paperwork is securely fastened together?!

Mail your application & proof of income to:Alley Cat Rescue P.O. Box 585Mt. Rainier, MD20712

Or drop off in person at:The BrentwoodAnimalHospital 3900 Rhode Island Ave.Brentwood, MD20722

WHAT HAPPENS NEXT?

Once your application has been reviewed, you will receive a phone callor email to inform you of your status of participation. If your application is accepted, further instructions for scheduling an appointment with the veterinarian will be discussed. If your application is denied, we will discuss the reason with you.

Alley Cat Rescue’s low-cost spay/neuter program is made possible thanks to individual contributors.

Rev. 10/15

277-5595

Dear Spay/Neuter Clinic Participant,

Thank you for contacting Alley Cat Rescue. Your decision to spay (female) or neuter (male) your companion animal will prevent unwanted litters from being born and then destroyed or living feral, because there are simply not enough homes for all of them. Each day in the U.S., an average of 70,000 kittens and puppies are born!

Dog and cat overpopulation is a serious problem in America. According to 1999 statistics, the PG CountyShelter’s euthanasia rate was approximately 12,000 animals per year. Nation-wide that figure is between 5 & 10 million…EVERY YEAR! The reason for this tragedy? Millions of kittens and puppies being born “by accident,” because pet owners did not bother to get their pets spayed or neutered!

The solution to this heartbreaking problem is simple and humane – by reducing the number of animals born “by accident,” we reduce the number of unwanted, homeless animals who will die. Spaying and neutering our companion animals,before they breed, will prevent the senseless deaths of millions of “throwaway pets,” who are dumped in shelters (or in woods, parking lots, along roadsides) across America each and every year.

Spay/neuter also allows your pet to live a longer and healthier life, since it will reduce, or even prevent, many common health and behavior problems such as the following:

Heat cycles, mammary cancer and pyometra (infected uterus) in female cats

Urine spraying, testicular cancer, roaming, fighting & spreading disease in male cats

What You Can Do To Help:

  1. Spay or neuter your own pets before they breed!
  2. Educate others - many people are not aware that pet overpopulation is such a huge problem.
  3. Help a family member, friend, or neighbor to get their pet “fixed” (spayed or neutered).
  4. Spay/neuter a stray cat or dog right away, before they have an unwanted litter!
  5. Help ACR to continue helping others – make a donation and become a member!

Attached is an application that will help us to determine your needs and qualification to participate in the low-cost program. Please take the time to read and fill out the entire application. We are unable to process incomplete applicationsand your qualification will be denied! We will contact you within 24-72 hours after your application has been received.

THANK YOU for taking the first step to being part of the humane solution to pet overpopulation!

Sincerely,

Alley Cat Rescue

Rev. 10/15