Free S and N application | Mississippi Spay And

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

County

Total number of animals

# Female Cats

# Male Cats

# Female Dogs

# Male Dogs

Are there any animals that will be left unaltered?

Yes

Are any under 2 lbs in weight?

Yes

Yearly Income

Are you receiving any type of government assistance?

If yes, please list

I understand that the funds are strictly used for spay and neuter surgery and that any charge beyond the surgery I may be responsible to pay.

I attest that I am the owner / person to authorize veterinary treatment / surgery / sterilization for my pet.

I have been informed and understand that there are risks inherent in any type of surgery and that in some cases, my pet may die or suffer serious effects during or after surgery.

Knowing these risks and the dangers associated with surgery, I hereby release and discharge Mississippi Spay and Neuter Initiative, all officers and directors and fund sponsors from any and all actions, claims, damages, loss of services, expenses and compensation on account of the surgical services to paid for by the organization Mississippi Spay and Neuter Initiative and fund sponsors.

Signature

Signature field is empty.

Date

Month

Day

Year