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.*

I certify under penalty of program disqualification that all information provided on this application is true, accurate, and complete. I understand that funding for this program is strictly limited to families experiencing true financial hardship. Providing false income information or falsifying government assistance documentation will result in immediate denial, permanent suspension from all future services, and potential liability for the full retail cost of the veterinary services rendered.*