Wisconsin and Ozaukee Humane Societies: Survey - Spay/Neuter Assistance Program Application

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Spay/Neuter Assistance Program Application

Please note:

Please send fees and proof of income to the campus you intend on visiting for the SNAP program.

If you are applying to the Milwaukee Campus, please send documentation and payment to:

SNAP Application
Wisconsin Humane Society: Milwaukee Campus
4500 W. Wisconsin Avenue
Milwaukee, WI 53208

If you are applying to the Ozaukee Campus, please send documentation and payment to:

SNAP Application
Wisconsin Humane Society: Ozaukee Campus
630 West Dekora St.
Saukville, WI 53080

*1.

Question - Required - Please select the campus you are applying to: Milwaukee Campus
Ozaukee Campus

General Information:

Name:

First Required	Last Required

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number: Required

*3.

Question - Required - How did you hear about the Wisconsin Humane Society Spay/Neuter Assistance Program?
Please make at least 1 selection from the choices below.

	Radio
	Family/Friend
	Wisconsin Humane Society
	Bus
	TV
	Veterinary Referral
	Website
	Other

Question - Not Required - If other, where?

*5.

Question - Required - Number of adults in your household?

*6.

Question - Required - Number of children in your household?

*7.

Question - Required - Number of cats in your household?

*8.

Question - Required - Number of dogs in your household?

*9.

Question - Required - Number of animals spayed/neutered in your household?

Household Income Verification

10.

Question - Not Required - Please check all that apply to your household. You will need to bring proof of qualification to your initial exam appointment.

	Forward card or proof of state medical benefits
	Quest card or proof of state food assistance
	Letter confirming current unemployment compensation
	College/University student ID
	Social Security statement
	Wisconsin Works statement
	Kinship Care statement

11.

Question - Not Required - If none of the above apply, you may qualify based on household income. Households with income at 70% or less of level qualify for SNAP services. Please check types of income and total monthly household income below. You will need to bring proof of qualification to your initial exam appointment.

	Employment income
	Retirement pension
	Worker's compensation
	Child support
	Help from family/friends
	Other

12.

Question - Not Required - Total annual gross household income of all adults in household:

Please remember to mail a $10 non-refundable fee for each animal to the appropriate campus.

Animal Information

Animal 1

*13.

Question - Required - Type:

*14.

Question - Required - Sex:

*15.

Question - Required - Spayed/Neutered:

*16.

Question - Required - Pregnant:

*17.

Question - Required - Name:

*18.

Question - Required - Age:

*19.

Question - Required - Breed:

*20.

Question - Required - Color/Markings:

Animal 2

21.

Question - Not Required - Type:

22.

Question - Not Required - Sex:

23.

Question - Not Required - Spayed/Neutered:

24.

Question - Not Required - Pregnant:

25.

Question - Not Required - Name:

26.

Question - Not Required - Age:

27.

Question - Not Required - Breed:

28.

Question - Not Required - Color/Markings:

Animal 3

29.

Question - Not Required - Type:

30.

Question - Not Required - Sex:

31.

Question - Not Required - Spayed/Neutered:

32.

Question - Not Required - Pregnant:

33.

Question - Not Required - Name:

34.

Question - Not Required - Age:

35.

Question - Not Required - Breed:

36.

Question - Not Required - Color/Markings:

37.

Question - Not Required - If you have additional concerns about your pet's health, please describe below. Please remember that this program only offers spay/neuter surgeries and initial preventative care at the time of surgery.

(Maximum response 255 chars, approx. 5 rows of text)

After we review your application, we will contact you to confirm that you qualify for the program and to set an appointment.

Please bring any medical records you have for your animal(s) to the first scheduled appointment for your animal.

*38.

Question - Required - I understand that I will be denied services if I do not qualify financially based on SNAP program guidelines, if I falsify any information on this application or if I do not provide documentation verifying that I qualify. I certify that I have reviewed the information on this application, that it is true to the best of my knowledge and that I am required to demonstrate financial need to receive any services. I also understand that I will only be permitted one cancelled or rescheduled appointment. If I cancel or miss a second appointment, it may be at least 6 months before the Wisconsin