Rescue ~ Rehab ~ Rehome

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone

Work Phone
x

Cell Phone

In which county do you live? You must live in Snyder, Union, Northumberland, Montour, Columbia or Lycoming to be considered.*

Please list all people who reside in the house. Including yourself list names, ages and relationship to you. *

How many in household are employeed? Number full time; part time or retired?*

What is your total household income? Proof of income is required. Please check your email for information on how to submit proof of income so we can get your appointment scheduled as soon as possible. *

Please list your Pitbull(s) and/or Pitbull mix(es). List their name(s), gender, age, breed and color. *

Haven to Home covers the cost of spaying or neutering your Pitbull or Pitbull mix. We currently do not cover costs of vaccinations, physical exam, additional blood work or any additional optional services you may choose to have done. Please check with your vet to find out what these services will cost. Costs vary by veterinarian. Please select a veterinarian.

How did you hear about the Pitbull Spay Neuter Program?*

I understand that Haven to Home and Petco Foundation involvement is limited to providing funds for the spaying/neutering of dog. By my signature, I release Haven to Home and the Petco Foundation of all liability resulting from this surgery. I also agree to pay any additional expenses incurred by this procedure to my chosen veterinary practice. Please type (sign) your full name and date.*