First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Cell Phone
What do you need assistance with?
How many dogs do you need help with and how much do they weigh?*
MEDICAL: Please let us know what you need help with medically for your dog(s)?
Are you able to pick any of the selected item(s) up or will you need assistance with pick up/drop off?* Choose one: Yes No
Please let us know any other information to best assist you and your pet.
We are delighted to assist you in keeping your dog as a cherished member of your family. Everyone occasionally needs a helping hand, and we are here to provide support with medical supplies, fencing, crates, and outdoor containment. The owner agrees that if they ever lose possession of the dog, they will notify the rescue, and all supplies must be returned immediately. Please type your name as a signature to this form *