Apply for Assistance

ACAP Application for Assistance

* Indicates required field

Applicant's Name *

Address (include county) *

Phone Number *

Email Address:

ACAP is an income-based program and requires verification of low-income and/or government benefits. To be eligible for the program, pet owners must agree to have their pets SPAYED OR NEUTERED if they are not initially, and will be referred to free or low-cost spay/neuter clinics. Questions with a red (*) next to them are required fields. Please answer all questions and click on "submit" once finished. ACAP is not equipped to respond to emergency situations and is an all-volunteer organization. If you prefer, you may call our message line at 540-850-2680 and someone will call you back as soon as possible. COPAYS will be $10 for veterinary visits & $10 for flea/tick/heartworm/dewormer medications. There is no cost for pet food when available. *

How did you hear about ACAP? *

Total number of cats/dogs you have: *

Are all your pets spayed (females) & neutered(males)? If not, which pets are not spayed/neutered? *

ACAP requires that ALL of your pets get spayed/neutered. Do you agree to get all of your pets spayed/neutered? (ACAP can help with the cost) *

Do you have transportation to/from a vet's office? *

Name & Age of Pet #1 *

Dog or Cat? *

Breed, Weight & Color *

Choose Any- Please note, ACAP requires all pets who receive assistance to be spayed or neutered. We can put you in touch with organizations that will provide this service at very low cost. *

SPAYED (FEMALES) NEUTERED (MALES) I AM WILLING TO SPAY/NEUTER

Describe your pet's veterinary needs: *

When was your pet last seen by a Veterinarian? (you can say "never" if applicable) *

Upload an image of Vet Records, rabies certificate, etc - you may also text a photo of records to 540-850-2680 *

Max file size: 20MB

Upload Photo of Pet - if you don’t have a photo of your pet please ask a friend or relative with a smart phone to take one for you and text it to 540-850-2680 with your name and the pet's name. *

Max file size: 20MB

Name & AGE of Pet #2 (leave blank if you have 1 pet) *

Dog or Cat? *

Breed, weight & color of pet *

Choose Any- Please note, ACAP requires all pets who receive assistance to be spayed or neutered. We can put you in touch with organizations that will provide this service at very low cost. *

SPAYED (FEMALES) NEUTERED (MALES) I AM WILLING TO SPAY/NEUTER

Describe pet's veterinary needs *

When was your pet last seen by a Veterinarian? (you can say "never" if applicable) *

Upload an image of Vet Records, rabies certificate, etc - you may also text a photo of records to 540-850-2680 *

Max file size: 20MB

Upload an image of your pet *

Max file size: 20MB

Name & AGE of Pet #3 (limit 3 pets) *

Dog or Cat? *

Breed, weight & color of pet *

Choose Any- Please note, ACAP requires all pets who receive assistance to be spayed or neutered. We can put you in touch with organizations that will provide this service at very low cost. *

SPAYED (FEMALES) NEUTERED (MALES) I AM WILLING TO SPAY/NEUTER

Describe your pet's veterinary needs: *

When was your pet last seen by a Veterinarian? (you can say "never" if applicable) *

Upload vet records/rabies certificate if available *

Max file size: 20MB

Upload photo of your pet *

Max file size: 20MB

Program Based Eligibility (to determine your financial eligibility for our program), the following information is required. Please select all applicable programs that you receive. You will need to provide proof of income by uploading supporting documents such as bank statements showing direct deposits, approval letters for government programs, etc. If you cannot upload documents, CLEAR photos of documents can be sent to us via text to 540-850-2680. Be sure to include your name on the text. *

How many children AND *adults (*everyone over 18 yrs of age) are in your household? *

Do you or does anyone in your household WORK? If so, WHO works and how much per week is earned? Doe anyone receive child support/alimony unemployment or a retirement? If so, WHO receives what and how much? *

Do you or does ANYONE in your household receive any government assistance, such as SNAP (food stamps), TANF, SSDI (disability), SSI (social security)? If so, who recieves it and how much is received per month? *

Upload Proof of Assistance or Income *

Max file size: 20MB

Upload Proof of Assistance or Income *

Max file size: 20MB

Upload Proof of Assistance or Income *

Max file size: 20MB

Upload Proof of Assistance or Income *

Max file size: 20MB

Photo Release: By checking this box I give my permission to ACAP to release photos of: *

My Pet(s) Myself & my Pet(s) Myself, other family members & my Pet(s) I decline all photo release permissions (ACAP uses these photos for fund raising and to show that we are helping pets in need. Our client's names will not be released)

ACAP is an income-based program and requires verification of low-income and/or government benefits. To be eligible for the program, pet owners must agree to have their pets sterilized if they are not initially, and will be referred to free or low-cost spay/neuter clinics. The program strives to encourage responsible pet ownership and will not provide assistance to those breeding animals. Eligibility will be terminated to those who have acquired new animals after being admitted to the program as this suggests financial means. There is a limit of three pets which the program can assist, and a $200 per pet limit. Any exceptions to these eligibility requirements must be approved by the Board. ACAP will assist in arranging immediate basic care needs such as diagnostic and wellness vet visits, vaccinations, and pest prevention. Depending on availability of funds, fencing, grooming, boarding, outdoor pet houses and other animal care services could be provided. ACAP will approve, coordinate and schedule all veterinarian services and monies will be paid directly to the approved vet by the organization. ACAP can deny any service(s) to anyone at the discretion of the ACAP board. *

I have read and agree to these terms and conditions. I agree to have my animals spayed/neutered per ACAP's requirement. I understand that ACAP may be able to help with the costs of spaying/neutering should I qualify for the program.

By checking this box, I certify that I am the owner or acting agent of the above-referenced animal(s). I am 18 years of age or older. I understand that Animal Care Assistance Program (ACAP) is funding flea/tick and dewormer medication, free or low cost veterinary treatment, and/or other animal care services to my animal(s), and that such treatment is not comprehensive. Products and services funded by ACAP are not meant as a substitution for regular veterinary examinations and treatment of acute or chronic health conditions. I understand that I must agree to have the above pet and any other household pets spayed or neutered, and that ACAP can help with the costs of spaying and neutering. I understand that should a veterinarian whose services are paid by ACAP discover any additional conditions present in my animal while providing services, or if any unexpected emergency situation should arise during the provision of services, I will be medically and financially responsible for any additional treatment required or for any complications that arise. During transport, ACAP is not liable for any accidents out of the transporter’s control. *

I agree to the terms of the ACAP program and this application

Submit