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[contact-form-7 id="No contact forms found" title="Contact"]
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Low-Income Owned Pet S/N Assistance Program Application
Please fill out one form per animal.
My pet is a...
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Cat living in Chaffee County
Dog living in Chaffee County
Pet Owner's Name
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First
Last
Referring organization and name/email of agent filling out application on behalf of owner (if applicable).
Physical Address.
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Street Address
Address Line 2
City
State
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District of Columbia
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Armed Forces Americas
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ZIP Code
Phone Number
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Email Address
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Pet's Name:
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Sex of Pet:
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Male
Female
Approximate weight:
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Approximate age:
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Primary Color:
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Secondary Color and/or Color Pattern:
Primary Breed:
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Secondary Breed:
Hair Type
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Short Hair
Medium Hair
Long Hair
Please let us know the amount you are able to afford as a co-payment at the time of your appointment (any amount is okay).
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Our program has limited grant funding and any amount you can provide will allow this program to help more animals.
Pet Medical History
Has your pet had a heat cycle?
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A heat cycle in pets typically appears as swelling of the vulva, increased licking of the genital area, and bloody vaginal discharge, often accompanied by changes in behavior such as increased affection or restlessness.
Yes
No
Unsure
If "yes", what was the date of your pet's most recent heat cycle?
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Write N/A if unsure.
Does your pet regularly take any medication?
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Yes
No
If "yes", please list the medications and their dose/frequency here.
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Ok to copy instructions from bottle.
Has your pet been diagnosed with, or have you noticed, any abnormality of the following systems?
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Eyes, ears, nose, mouth
Skin, coat
Skeletal (for example: deformity, recent or past injury, bone cancer, etc.)
Respiratory
Cardiovascular
Neurological
Other
None of the above
If you checked any boxes above, please briefly describe here:
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Does your pet require any special handling at the vet?
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For example: Muzzle, additional restraint, etc. If your pet has not visited a vet, please describe your pet's behavior with strangers and/or handling.
Additional Options
Is your pet up to date on their rabies vaccination?
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Yes
No
Unsure
Please provide the date of rabies vaccination and the state/name of the clinic that vaccinated your pet. Alternatively, you can upload a photo of your pet's rabies certificate below.
Optional: Upload a photo of your pet's rabies certificate here.
Max. file size: 256 MB.
Would you like your pet to receive a free rabies vaccine at the time of surgery?
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The rabies vaccine protects against rabies, a deadly viral disease that affects the nervous system and can be transmitted to humans, making it crucial for both animal and public health protection.
Yes
No
Would you like your pet to receive a free distemper combo vaccine at the time of surgery?
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RCP vaccination for cats, DAPP vaccination for dogs. RCP (cats) protects against feline rhinotracheitis (herpesvirus), calicivirus, and panleukopenia, while DAPP (dogs) protects against distemper, adenovirus (hepatitis), parvovirus, and parainfluenza—all highly contagious and potentially fatal diseases, making these core vaccines essential for preventing serious illness and death.
Yes
No
Has your pet previously been vaccinated with a distemper combo vaccine?
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Yes
No
Unsure
Do you want free microchipping for your pet at the time of surgery?
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A microchip is a permanent way to link your contact information with your pet. It contains only a unique identifying number, stores no further information, and is not able to be tracked. Your contact information is stored with the microchip company and you are able to control privacy of this information. If your pet's chip is scanned, the microchip company is contacted by the organization who has scanned it (usually a vet clinic or animal shelter). Your contact preferences are then followed.
Yes
No
Would you like to purchase a post-surgical cone (E-collar) to help prevent your pet from licking or irritating the incision site during recovery?
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The cost for animal cones is $5. This cost is separate from any co-pay amount, with payment due at the time of surgery. This purchase is optional and may be added or declined on the day of the procedure. Cones will be fitted by AVHS staff at the time of surgery.
Yes
No
Unsure
Would you like to purchase pre-surgical blood work at the time of your pet’s surgery?
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The cost for pre-surgical bloodwork is $85. This screening helps assess underlying conditions and overall health prior to anesthesia, for your pet’s safety. This cost is separate from any co-pay amount, with payment due at the time of surgery. This purchase is optional and may be added or declined on the day of the procedure.
Yes
No
Unsure
Required Documents
Please attach a photo of your pet:
Max. file size: 256 MB.
Please attach a copy of your drivers license or other official document that includes your name and local address:
For proof of residency in Chaffee County.
Max. file size: 256 MB.
Please attach proof of low income/unsheltered status:
May include: Proof of enrollment in CO assistance programs (such as SNAP, Health First Colorado/Medicaid, Social Security Disability, etc.), or A letter of referral confirming low-income or unsheltered status from a referring agency, or An application completed on the pet owner’s behalf by a staff member from a referring agency. Referring agency examples: Law enforcement, a human services agency such as Chaffee County Hospitality, the Department of Human Services, Solvista, any church, The Mission, The Grainery, the Caring & Sharing Resource Center, etc.
Max. file size: 256 MB.
Consent Questions
Spay Tattoo Agreement
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The pet owner understands that all female pets will receive a small standard tattoo to visually indicate that the animal has been spayed.
Consent to Share Information
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The pet owner agrees that the information on this form is correct and allows Ark-Valley Humane Society to share the information provided with the supporters of the program (private parties, foundations, governments) for the purpose of documenting this spay/neuter program.
After submitting the application please keep an eye on your email for further instructions. You'll receive a follow up email soon.
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