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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Can we text this phone number?*
    -- Select One --YesNo

    Select one

14. Email Address*
16. Are you a representative of a rescue or shelter applying for spay/neuter of an animal in care of the organization?*

    1. Yes
    2. No

    This does NOT include if you have adopted an animal from a rescue or shelter.

17. If "Yes", what is the name of the organization?
19. How many total dogs will you need assistance with?
    -- Select One --123

    Dogs must weigh a minimum of five (5) pounds and a maximum of 90 pounds to be eligible.

21. Has the dog(s) been in your care for over 30 days?*

    1. Yes
    2. No
22. Legally, an animal must be in your care for over 30 days before ownership is claimed. Please re-apply in 30 days. *

    1. I will re-apply in 30 days.
24. Dog Name
25. Dog Age (Estimate)*
26. Color
27. Secondary Color
29. Gender*
    -- Select One --MaleFemale
30. Weight*
31. Breed*
32. Is this dog microchipped?*

    1. Yes
    2. No
    3. Unknown
36. Dog Name
37. Dog Age (Estimate)
38. Color
39. Secondary Color
41. Gender
    -- Select One --MaleFemale
42. Weight
43. Breed
44. Is this dog microchipped?

    1. Yes
    2. No
    3. Unknown
48. Dog Name
49. Dog Age (Estimate)
50. Color
51. Secondary Color
53. Gender
    -- Select One --MaleFemale
54. Weight
55. Breed
56. Is this dog microchipped?

    1. Yes
    2. No
    3. Unknown
58. If any known medical conditions for any of the dogs, please explain:
60. How did you get your dog(s)

    1. Appeared / Found on my property or neighborhood
    2. Given to me by a friend / family member

    1. Online / Social Media (eg. Facebook Marketplace, Craigslist)
    2. Other

    (Check all that apply)

62. How did you learn about our dog spay/neuter program?*

    1. Companion Project
    2. Flyer or Other Promotional Materials
    3. Media Announcement
    4. Other WCAC Program (ex. adoption, volunteerism, "Paw Pantry", etc.)
    5. Social Media or Website
    6. Word of Mouth
64. On the day of surgery your dog will receive a spay or neuter surgery. You may elect to also purchase the following (check all that apply):

    1. Microchip $15
    2. DAPPV $15
    3. Dewormer $15
    4. Heartworm Test $20
    5. Rabies Shot $10 (required if proof of current rabies is not provided)
66. To your knowledge, do any of the dogs listed above have a medical condition?*

    1. Yes
    2. No
    3. Unknown
68. If "Yes", please describe:

    If more than one dog has a known medical condition, please identify which dog has which condition.

70. For Male Dogs Only: To your knowledge, are any of your male dogs cryptorchid?*

    Cryptorchidism is a condition in which one or both of the testes fail to descend.  Additional fees apply to neuter such animals.

    1. Yes
    2. Don't Know
    3. No
    4. Applying for Female Dog(s) Only
72. If there is anything else that you think it would be helpful for us to know about the dog(s), please describe:
74. How many total persons live in your household?*
76. Have any of your animals that need spayed or neutered ever shown aggression (towards dogs or people) in a vet setting?*
    -- Select One --YesNo
78. If yes, please explain:
80. Total Household Income*
82. If no household income, please explain:

84. Those who qualify may receive free vaccinations for their pet courtesy of Petco Love and the "Vaccinated & Loved" initiative to help end life-threatening pet diseases. 

86. By signing this document and registering for an appointment, you are giving our clinic consent to perform surgery on your pet. Our staff will always answer questions, address concerns and ensure that you have a high-quality experience, but you will not meet or speak with a veterinarian prior to or following the procedure. You will receive detailed medical records.*

    1. Acknowledged
88. 1. I understand that through the income-based spay-neuter program my dog(s) will receive spay or neuter, and rabies shot if I am unable to provide current proof.*
    Initial
90. 2. I understand that the spay/neuter surgery carries a risk of complications, including death or in the case of spay surgery, potential termination of previously unknown pregnancy, to the animal(s). I hereby assume full responsibility and agree to waive any and all claims against Williamson County Government and Williamson County Animal Center ("WCAC") and their agents, officers, veterinarians, contractors, volunteers and employees in the event of escape, sickness, injury, complications or death of my animal(s) related to the spay/neuter surgery.*

    Initial

92. 3. I understand that animals may be groggy when released, and should be kept in an enclosed area for 24 hours after the procedure. I will make every attempt to observe the dog for post-surgical complications including, but not limited to, incision infection and lack of appetite. In case of post-surgical problems, I agree to arrange the appropriate veterinary care at a full service facility at my own expense.*

    Initial

94. 4. I agree to retrieve my dog(s) the same day as surgery. Dog(s) not picked up the day of surgery may be considered abandoned and subject to citation.*

    Initial

96. 5. To the fullest extent permissible under applicable law, I agree to hold harmless, indemify, and release Williamson County Government, and WCAC, their agents, officers, veterinarians, contractors, volunteers, and employees, from any and all loss, injury, liability, damage, or cost I may incur or suffer due directly or indirectly from the spay / neuter surgery and removal and housing of this animal whether caused by Williamson County Government or WCAC, their officers, agents, veterinarians, volunteers or employees. *
98. 6. I VOLUNTARILY SIGN THIS RELEASE AND WAIVER OF LIABILITY, and further agree that no oral representations, statements or inducements, apart from this written agreement have been made. I further attest that the above listed dog is my pet or in my custody of care, and that I have the authority as the owner or agenty to authorize the removal and housing by WCAC.*
100. I HAVE READ AND UNDERSTAND THE ABOVE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT AND I AGREE TO BE LEGALLY BOUND BY ALL TERMS AS PERMITTED BY APPLICABLE LAW.*
     Signature of Owner or Agent:
101. Date*

103. *Please be sure to check your spam/junk folder if you do not receive a response to your application within 2-3 business days.*

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105. 1. Receive an email copy of this form.
106. Email address

     This field is not part of the form submission.

107. Submit

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