Outreach Application - Detroit Dog Rescue

Part 1: Getting To Know You

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Employer

Are you a federal worker going without pay?*

What branch?*

Do you receive any state assistance?*

Are you a recipient of WIC?*

Do you receive assistance from any other animal organization?*

Please Explain:*

Please explain what other assistance you receive from other animal organizations.

How many people live in your household including yourself?*

Please enter a number from 1 to 20.

What is your total annual household income?*

This 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 Dog

How many dogs do you own at this address?*

Is your dog(s) licensed through the city of Detroit?*

Yes
No

Is your dog(s) microchipped?*

Yes
No

Is your dog(s) vaccinated against:*

Rabies
Parvo
Lepto
None

Check each item that your dog(s) is vaccinated against.

Dog #1

Dog #1 Name*

Dog #1 Breed*

Dog #1 Age*

Please enter a number from 0 to 25.

Dog #1 Sex*

Is Dog #1 spayed or neutered?*

Outreach Spay/Neuter Program*

Yes
No

Would you agree to let Detroit Dog Rescue spay or neuter this dog through our outreach program?

Dog #2

Dog #2 Name*

Dog #2 Breed*

Dog #2 Age*

Please enter a number from 0 to 25.

Dog #2 Sex*

Is Dog #2 spayed or neutered?*

Outreach Spay/Neuter Program*

Yes
No

Would you agree to let Detroit Dog Rescue spay or neuter this dog through our outreach program?

Dog #3

Dog #3 Name*

Dog #3 Breed*

Dog #3 Age*

Please enter a number from 0 to 25.

Dog #3 Sex*

Is Dog #3 spayed or neutered?*

Outreach Spay/Neuter Program*

Yes
No

Would you agree to let Detroit Dog Rescue spay or neuter this dog through our outreach program?

Dog #4

Dog #4 Name*

Dog #4 Breed*

Dog #4 Age*

Please enter a number from 0 to 25.

Dog #4 Sex*

Is Dog #4 spayed or neutered?*

Outreach Spay/Neuter Program*

Yes
No

Would you agree to let Detroit Dog Rescue spay or neuter this dog through our outreach program?

Outreach Needs

Let us know what you are in need of so we can better prepare.

What are your needs?*

Please check the boxes that apply to your needs.

At this time we are unable to provide dog houses, straw, or vaccines for our outreach dogs. However, we are still providing food to those in need.

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.