Outreach ApplicationStep 1 of 333%Part 1: Getting To Know YouName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email EmployerDo you receive any state assistance?*YesNoAre you a recipient of WIC?*YesNoDo you receive assistance from any other animal organization?*YesNoPlease Explain:*Since you answered yes to the above question about receiving assistance from another animal organization, please explain in detail here.How many people live in your household including yourself?*Please enter a value between 1 and 20.What is your total annual household income?*$0.00-$5,000$5,000-$10,000$10,000-$15,000$15,000-$20,000$20,000-$25,000$25,000-$30,000$30,000-$35,000$35,000-$40,000$40,000-$45,000$45,000-$50,000This number should include any child support, rental income, or extra income collected for the entire household. Please check one the following amount that applies to your household.Part 2: Getting To Know Your DogHow many dogs do you own at this address?*12345678910Dog #1Dog #1 Name*Dog #1 Breed*Dog #1 Age*Please enter a value between 0 and 25.Dog #1 Sex*MaleFemaleIs Dog #1 spayed or neutered?*YesNoOutreach Spay/Neuter Program*YesNoSince you answered no, will you agree to let Detroit Dog Rescue spay or neuter this dog through our outreach program?Dog #2Dog #2 Name*Dog #2 Breed*Dog #2 Age*Please enter a value between 0 and 25.Dog #2 Sex*MaleFemaleIs Dog #2 spayed or neutered?*YesNoOutreach Spay/Neuter Program*YesNoSince you answered no, will you agree to let Detroit Dog Rescue spay or neuter this dog through our outreach program?Dog #3Dog #3 Name*Dog #3 Breed*Dog #3 Age*Please enter a value between 0 and 25.Dog #3 Sex*MaleFemaleIs Dog #3 spayed or neutered?*YesNoOutreach Spay/Neuter Program*YesNoSince you answered no, will you agree to let Detroit Dog Rescue spay or neuter this dog through our outreach program?Dog #4Dog #4 Name*Dog #4 Breed*Dog #4 Age*Please enter a value between 0 and 25.Dog #4 Sex*MaleFemaleIs Dog #4 spayed or neutered?*YesNoOutreach Spay/Neuter Program*YesNoSince you answered no, will you agree to let Detroit Dog Rescue spay or neuter this dog through our outreach program?Part 2 ContinuedIs your dog(s) licensed through the city of Detroit?*YesNoIs your dog(s) microchipped?*YesNoAre your dogs vaccinated against:* Rabies Parvo LeptoCheck each item that your dogs are vaccinated against.What are your needs?* Dry Kibble Wet Food Dog House Straw for dog house insulation Leash Collar Safe tie out Flea/Tick preventative Fly treatment Detroit Dog License Rabies VaccinationPlease check the boxes that apply to your needs.Any other pets?Do you have any other pets in the home? If so, please explain and tell us about their needs as well. Although we primarily care for dogs, we may be able to help you find other resources. This iframe contains the logic required to handle AJAX powered Gravity Forms.
